Every finding on record at Complete Care at Fair Lawn Edge

Complaint # 2693362 Based on observation, interviews and review of other pertinent facility documents on 12/22/2025,12/23/2025 and 12/29/2025, it was determined that the facility failed to develop and implement a procedure to safely acquire and receive physician ordered Methadone, (a controlled Substance) from a third party clinic; by assigning an unlicensed staff a Certified Nursing Assistant (CNA #1) to travel to an outside third party clinic to pick up Methadone (a controlled substance) for Residents #6,#7 and #8. CNA #1 would take the locked box with the key which contained the Methadone and drive to the facility in her personal car. An interview with the third-party's clinic staff and with facility's CNA #1 confirmed that CNA #1 picked up Methadone from the outside clinic and had access to the key for the box with the Methadone. Review of document from the third-party clinic which was provided to the Department of Health (DOH) by the facility, stated that CNA #1 performed this function of picking up the Methadone for residents on 11/19/2025 until 12/15/2025. During an interview on 12/22/2025 at 1:07 PM, with the Director of Nursing (DON), the surveyor asked the DON for the policy and procedure on receiving Methadone from the outside third part clinic. The DON stated that the facility had no policy. The DON confirmed the facility had residents on Methadone, and that a Certified Nursing Assistant (CNA) or a nurse picked up the residents' Methadone from the clinic weekly or biweekly. The DON further stated that the Methadone was usually transported in a locked box by the nurse or CNA and was given to the unit nurse where the resident was located. The DON stated that she had an assigned CNA that picked up the Methadone from the third-party clinic, and if the assigned CNA was off, an arrangement was made for the CNA to come in for a couple of hours to go and pick up the Methadone.During an interview on 12/23/2025 at 1:56 PM, the Consultant Pharmacist stated that Methadone Clinic was not under his jurisdiction.During an interview on 12/23/25 at 2:16 PM, CNA #1 confirmed that she picked up Methadone from the outside clinic and that she delivered the box of Methadone and the key to the ADON or the DON when she arrived at the facility, and there were no discrepancies. During an interview on 12/29/25 at 9:25 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), stated that they did not have a specific policy and procedure for picking up Methadone from the outside clinic and that they used their general narcotic policy. The LNHA stated, that their corporate office only had the general narcotic policy but nothing specific about picking up Methadone.According to facility's policy dated 9/1/2024, with a revision date of 3/6/2025 and titled: Controlled Substance Administration and Accountability, it stated that controlled substances are delivered and signed for a licensed nurse.During an interview on 12/29/25 at 10:08 AM, the Registered Nurse (RN #1) stated that a CNA should not pick up Methadone because it was a narcotic medication, and CNAs do not handle narcotics or any type of medication. RN #1 further stated that a CNA should not handle or deliver narcotics or any sort of medication because they are not licensed. NJAC 8:39-29.4(k); 29.7(c)

Based on observation, interview, and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 2 of 2 units (3rd and 4th floors) and 2 of 2 shower rooms.This deficient practice was evidenced by the following:On 8/13/25 at 9:55 AM, the surveyor with the Housekeeping Director (HD) toured the 3rd floor and observed the following inside the shower room:-Upon entry, toward the right side of the shower room in the 1st cubicle, there was a shower chair with ripped chair cover, and across the 1st cubicle was a plastic tray. The 1st cubicle wall tiles and moldings with yellowish stain. The HD informed the surveyor that the plastic tray was part of a wheelchair that should have not on the floor. The HD confirmed that the tiles should have been cleaned.-The 2nd cubicle floor safety strips were peeling off. The HD stated that the safety strips were safety measures to prevent resident from falling while in shower and should have been fixed. Both the surveyor and the HD observed the ceiling tile with big dried brownish discoloration, tiles stained with yellowish substances, and the ceiling was not totally covered. The HD stated that should have been fixed and floor should be cleaned. -The 4th cubicle safety strips were peeling off, the floor and tiles stained with blackish substances, and no privacy curtain. -The 5th cubicle floor and tiles on the walls stained with blackish substances.-The 6th cubicle safety strips were peeling off. On that same date and time, both the surveyor and the HD observed the soiled utility room with two ceiling tiles with brownish discoloration.On 8/13/25 at 10:10 AM, both the surveyor and HD observed the 4th floor clean linen room with accumulation of grayish substances on the ceiling vent and the HD stated should have been cleaned. At that same time, both the surveyor and the HD observed the 4th floor shower room and observed the following:-The 2nd cubicle privacy curtain with missing hooks.-The 6th cubicle tile walls and floors stained with yellowish substances. On 8/13/25 at 10:15 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of the 4th floor and the LPN Supervisor (LPNS). The surveyor observed the eyewash area in the nursing station with heavy accumulation of grayish substances and the RN/UM stated that were dust and should have been cleaned. The Assistant Director of Nursing (ADON) donned (put on) gloves and stated she would clean it. Afterward, the surveyor, RN/UM, and LPNS went to the 4th floor panty area, and observed the ceiling vent with heavy accumulation of grayish substances. Both the LPNS and RN/UM stated that should have been cleaned. On 8/13/25 at 10:21 AM, the surveyor with the RN/UM went to the 4th floor dining room and both observed two residents seated near the two vending machines and on top of them was a vent in the ceiling with heavy accumulation of blackish substances. There were total of 10 residents and two facility staff inside the room.Outside the room, the RN/UM stated that the vent should have been cleaned, and she did not know why it was not cleaned. She further stated that she would ask the housekeeper to clean them. The RN/UM informed the surveyor that the two residents were Resident #111 and Resident #30.On 8/13/25 at 1:49 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing (DON), [NAME] President of Clinical Services (VPoCS), and the surveyor notified them of the above observations, concerns, and findings with regard to environment. The VPoCS stated that all those concerns of the surveyor had been addressed after surveyor's inquiry. A review of the facility's Safe and Homelike Environment Policy that was provided by the VPoCS, with implemented date of 9/1/24, revealed under policy: in accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use their personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Under policy explanation and compliance guidelines .#3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 4. The facility will provide and maintain bed and bath linens are clean and in good condition .9. General Considerations: .a. Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to Housekeeping Department .A review of the facility's Routine Bathroom/Shower Cleaning Policy that was provided by the VPoCS, with implemented date of 9/1/24, revealed under policy: it is the policy of the facility to establish policies, procedures and guidelines to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of healthcare associated infection.Procedure: 1. Working form clean areas to dirty areas: h. Clean shower/tub faucets, walls and railing, scrubbing as required to remove soap scum. Inspect grout mold, apply disinfectant to interior surfaces of shower/tub, including soap dish, faucets and shower head.Inspect shower curtain and replaced as required.4. Report areas of mold, cracked, leaking or damaged items in need of repair.NJAC 8:39-31.4(a)(b)(f)

Based on the interview and review of other facility documentation, it was determined that the facility failed to issue the Notice of Medicare Non-coverage (NOMNC, which is an official document issued by Medicare-certified healthcare providers and serves as a formal notice informing beneficiaries about the termination or denial of coverage for specific health care services) or Form CMS - 10123, required notice for 1 of 3 residents (Resident #182) reviewed for beneficiary notification. This deficient practice was evidenced by the following On 8/11/25 at 10:51 AM, the surveyor reviewed the NOMNC or Form CMS -10123 review completed by the facility for Resident #182 as follows: A review of the Progress Notes (PN) dated 4/9/25 at 4:19 PM stated that the resident was transferred to another health care facility. A review of the electronic Medical Records (eMR) revealed that there was no documented evidence that the NOMNC was done, nor the reason why it was not done. A review of the physician certification and re-certification form with a handwritten name of Resident #182 and with a handwritten discharge date of 4/9/25, signed by the physician on 3/29/25. A review of the NOMNC letter provided by the Licensed Nursing Home Administrator (LNHA) on the same day revealed a handwritten name of the resident stating the effective date coverage of your current: skilled nursing services will end with a handwritten date of 4/18/25. Resident #182's name signed the letter with the date on 4/16/25. On 8/11/2025 at 11:28 AM, the surveyor interviewed the Director of Social Services (DSS), who stated that the NOMNC form should be signed at least 72 hours or 2 days before the resident will be discharged to home or other facility. The DSS did not provide additional information on why the date was not correct on the letter. On 8/11/2025 at 12:05 PM, the surveyor interviewed the LNHA, who stated that he does not know what happened, but the date should be checked before the resident signed it. The NOMNC letter should be signed on the 7th of April, 2 days before the resident leaves home or other nursing home. 08/11/2025 12:12 PM, the surveyor interviewed the Director of Nursing (DON). The surveyor notified the DON of the above findings and concerns with Resident#182's NOMNC form. The DON stated that Resident #182 left on 4/9/25 for another nursing home. The DON confirmed that the resident should have a NOMNC done. NJAC 8:39-5.4 (b)(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to consistently follow standards of clinical practice by following a physician's order for the administration of medications and clarifying a physician's order for 2 of 5 residents (Resident #19 and #21). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as 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. 1. On 8/13/25 at 7:51 AM, the surveyor and the Licensed Practical Nurse/Unit Manager (LPN/UM) observed Resident #19 in bed with the head of the bed flat. The surveyor observed that when the LPN/UM raised the head of the resident's bed, the resident stated, I hurt, I hurt. The LPN/UM replied that she would inform the LPN staff nurse assigned to Resident #19 to administer the resident's tramadol (pain medication). The surveyor reviewed Resident #19's medical record. A review of Resident #19's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's Disease, diabetes mellitus, and a stage 4 pressure ulcer (extensive tissue damage that extends into the muscle and bone) of the sacral region (tailbone area). A review of a Physician's Order dated 7/7/25 and transcribed onto the Medication Administration Record (MAR) indicated tramadol hcl 50 milligrams (mg), give one tablet by mouth every 8 hours as needed for moderate to severe pain level of 4-10.; PO dated 2/19/25 for tramadol Hcl 50 mg PO give one time a day before wound care. A review of a Physician's Order dated 7/11/25 and transcribed onto the Treatment Administration Record (TAR) indicated to cleanse the sacral wound every evening and night shift with acetic acid 1%, apply skin prep to the surrounding tissue, pack with calcium alginate, and secure with a bordered foam dressing. A review of the July 2025 MAR revealed the nurses signed for the tramadol from 7/1 through 7/31/25 as given at 9:00 AM, before wound care. A review of the August 2025 MAR revealed the nurses signed for the tramadol from 8/1 through 8/13/25, as administered at 9:00 AM, before wound care. A review of the July and August MARs indicated the nurses had not administered the pain medication according to the physician's order before providing the wound treatment during the evening or night shift but had administered it once daily at 9:00 AM. A review of the July TAR revealed that the nurses signed that the treatment was administered during the night shift. A review of the August TAR revealed that the nurses signed from 8/1 through 8/13/25 that the wound treatment was administered during the evening and night shift. A review of the Quarterly MDS, an assessment tool dated 7/31/25, reflected that Resident #19 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. Section M reflected that the resident had one stage 4 unhealed pressure ulcer present on admission. A review of Resident #19's Care Plan revealed a Focus area that included but was not limited to; the resident has an actual pressure ulcer to his/her sacrum. Interventions included to administer medication for pain as needed and reassess; provide a pressure-relieving mattress, provide wound treatment as ordered; weekly wound assessment; and weekly wound skin evaluation by wound team. A review of the Wound Assessment Report dated 6/5/23 (Present on Admission) reflected a wound to the sacrum stage 4; 2.00 centimeters (cm) x 1.20 cm x 3.00 cm (depth) with treatment orders which indicated to cleanse the wound with 0.125% wound cleaning solution, apply skin prep to peri-wound, and use Dakins moistened fluffed gauze bordered with foam daily. A review of the Wound Assessment Report 8/6/25 revealed: stage 4 st sacrum; .7x.7x1.0 cm depth 100% granulation; stable; with orders to cleanse with Acetic Acid 1% pack with Calcium Alginate with silver; cover with bordered foam dressing two times a day. On 8/13/25 at 9:00 AM, during an interview with the surveyor, the regional nurse stated that Resident #19's niece (POA) would not allow the surveyor to observe the resident's sacral wound treatment. On 8/14/25 at 10:00 AM, during an interview with the surveyor, the LPN assigned to resident 19's care confirmed that he should have clarified the 9:00 AM, tramadol order with the physician, as he had not provided the wound treatment on the day shift. On 8/14/25 at 1:15 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and [NAME] President of Clinical Services (VPCS). The VPCS acknowledged that Resident #19 should have received their tramadol before the stage 4 wound treatment was provided per the physician's order and confirmed the treatment was being done on the evening and night shifts. The VPCS confirmed that it was the responsibility of the LP/UM to review Physician Orders. A review of the facility's policy Following Physician Orders dated 9/1/24 reflected .Medications must be administered in accordance with the orders, including any required time frame . 2. On 8/13/25 at 9:59 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #21. The admission Record (a summary of important information about the resident) documented Resident #21 had diagnoses that included but were not limited to, heart failure, hypertension (high blood pressure), and benign prostatic hyperplasia (enlarged prostate). A comprehensive Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, dated 6/20/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #21 scored a 7 out of 15, which indicated the resident had severe cognitive impairment. A physician's order dated 6/17/25 indicated finasteride 5 milligrams (mg), give 1 tablet by mouth in the afternoon for BPH; Hold if Systolic Blood Pressure (SBP) less than 110, Hold if heart rate (HR) less than 60. A review of the June 2025 Medication Administration Record (MAR) revealed the nurses signed for the finasteride medication from June 19th to June 30 as administered. There was no documentation on the MAR entry of the resident's BP and HR at the time of administration. A review of the July 2025 Medication Administration Record (MAR) revealed the nurses signed for the finasteride medication from July 1st to July 31 as administered. There was no documentation on the MAR entry of the resident's BP and HR at the time of administration. A review of the August 2025 Medication Administration Record (MAR) revealed the nurses signed for the finasteride medication from August 1st to August 12th as administered. There was no documentation on the MAR entry of the resident's BP and HR at the time of administration. On 8/13/2025 at 10:59 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) in the presence of the Assistant Director of Nursing (ADON) about medications with BP and HR parameters. The RN/UM stated the nurses checked the resident's BP at the time the medication was to be administered, and the results would determine whether the nurse held the medication or administered the medication according to the physician's orders. The RN/UM further explained that the nurses documented the BP and HR results in the MAR or in a progress note. The surveyor reviewed with the RN/UM, the finasteride entry on the MAR of Resident #21. The surveyor discussed the concern that there was no documentation of the resident's BP and HR at the time of the medication's administration. The surveyor with the RN/UM reviewed the documented BP and HR in the vitals section of the EMR. The RN/UM confirmed the nurses did not document the BP and HR obtained for every finasteride administration. The RN/UM stated it was expected for the nurses to read the physician's order which included the parameters and they should document the BP and HR results at the time of administration. On 8/13/2025 at 11:17 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) in the presence of a Registered Nurse (RN) about medications with parameters. The LPN stated it was expected for nurses to follow the physician's orders for medications with parameters. The LPN explained the nurses checked the applicable vital signs at the time of a medication's administration and then documented the results in the MAR entry when prompted. The surveyor asked the LPN what would happen if the entry did not prompt the nurse to enter a result. The LPN replied that a note should be written to include the results obtained at the time of administration to show why the medication was given or not given to the resident. On 8/13/2025 at 11:40 AM, the surveyor interviewed the Director of Nursing (DON) who stated medications with parameters should be followed as per the physician's order. The DON explained the nurses checked the vital signs before administering a resident's medication as per the physician's parameter orders. The DON further stated the nurses documented the results in a drop-down box on the MAR and if they there was no drop-down box, the nurses could add it to the order entry or write a progress note documenting the results. The surveyor with the DON reviewed Resident #21's finasteride order entry in the MAR. The DON stated she would have to review the resident's EMR as this was not a standard for finasteride to have parameters and that it may have been entered in error. The DON stated she would follow up and provide the surveyor with additional information. On 8/13/2025 at 1:49 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Clinical Services (VPCS) about the above concern for Resident #21's finasteride order. There was no verbal response at this time by the facility. On 8/14/2025 at 1:06 PM, the LNHA, the DON, and the VPCS informed the survey team Resident #21's finasteride order was clarified with the physician, that there was no need for parameters and the medication should not have had parameters. There was no additional information provided by the facility. The surveyor reviewed the facility provided policy titled, Medication Administration, dated 9/1/2024. Under Policy revealed: . Medications are administered by licensed nurses, or staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The Policy Explanation and Compliance Guidelines of the policy revealed: . 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.21. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR.23. Correct any discrepancies and report to nurse manager.11. The following information is checked/verified for each resident prior to administering medications .b. Vital signs, if necessary.21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident receive treatment and care as specified by hospital discharge orders, in accordance with professional standards of practice and facility policies and procedures for 1 of 35 residents (Resident #169) reviewed. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 8/12/2025 at 10:30 AM, the surveyor observed Resident #169 lying in bed. The resident stated that they have been in the facility for 1 year and 5 months. The resident stated that they were in the hospital a few months ago because they could not breathe, and that they called 911. The resident stated that they received liquid antibiotics in the hospital.On 8/12/2025 at 10:39 AM, the surveyor interviewed the License Practical Nurse (LPN) #1, who stated that the resident had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), a lung condition that obstructs airflow, making it difficult to breathe. The LPN further stated that the resident was sent to the hospital for shortness of breath and returned to the facility with a nebulizer (a small machine that turns liquid medication into a mist so that it can be inhaled). On 8/12/2025 at 12:05 PM, the surveyor reviewed the medical records which revealed diagnoses which included but not limited to COPD with acute exacerbation and other asthma. A review of the physician order summary revealed:-Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (Fluticasone Furoate Vilanterol) 1 puff inhale orally one time a day for COPD -Order Date 3/20/2025. -Montelukast Sodium Oral Tablet 10 MG (Montelukast Sodium) Give 1 tablet by mouth one time a day for COPD -Order Date 3/20/2025. -Tiotropium Bromide Monohydrate Inhalation Capsule 18 MCG (Tiotropium Bromide Monohydrate) 1 inhalation inhale orally one time a day for COPD -Order Date 3/20/2025. -Albuterol-Budesonide Inhalation Aerosol 90-80 MCG/ACT (Albuterol-Budesonide) 1 puff inhale orally every 6 hours as needed for SOB/ Wheezing -Order Date 3/20/2025. -Ipratropium-Albuterol Solution 0.5- 2.5 (3) MG/3ML 3 ml inhale orally via nebulizer every 4 hours as needed for congestion, sob **Before treatment obtain LS, O2, Respiration **After treatment Obtain LS, O2, Respiration, number of minutes spent completing treatment LS 1=clear 2=diminished 3=crackles 4=wheezes 5=bronchospasms **Rise and spit after each use** -Order Date 5/14/2025. A review of the Quarterly Minimum Data Set (MDS), an assessment tool that facilitates the plan of care, dated 7/2/25, revealed a Brief Interview Mental Status (BIMS) score of 15 out of 15, indicating the resident had intact cognition.A review of a nursing progress note date 3/19/25, revealed Resident #169 had complained of chest congestion and cough. The nurse gave the resident a breathing treatment and cough syrup. The resident called 911 to go to hospital and left against staff nurse and supervisor advise. The Medical Director (MD) was made aware.A review of the Emergency Department (ED) notes dated 3/19/25, revealed the resident complained of chest pain, a cough for 3 days, and had a primary medical history of COPD. A chest x-ray (CXR) was done which revealed no infiltrate (abnormal accumulation of a substance other than air within the lungs). The resident was given nebulizer treatments and steroids (medication used to reduce inflammation). A review of blood work that was drawn revealed unremarkable results. The resident was readmitted back in the facility on 3/20/25.On 8/12/2025 at 1:00 PM, the surveyor requested from the Regional [NAME] President of Clinical Services, any pulmonology consult notes. On 8/13/2025 at 11:24 AM, the surveyor reviewed the residents Emergency Department's discharge instructions dated 3/20/2025, which revealed to follow up with the primary care provider within 2 to 4 days; pulmonary services within 1 month; to contact the office of the lung doctor for post hospital follow up appointment; and follow up Cat Scan (CT)(a medical imaging technique used to obtain detailed internal images of the body) of the chest for July of 2025.A further review of the Nurse Practitioner (NP) notes dated 3/23/25 at 1:30 revealed, the resident called 911 for shortness of breath. was brought to the Emergency Department (ED). The resident stayed in the hospital for observation for COPD exacerbation. The resident was discharged back to the facility and advised follow-up with Pulmonologist. On 8/13/2025 at 10:00 AM, the Regional Nurse provided to the surveyor a pulmonology consult completed via telemedicine (use of digital technology to deliver healthcare services remotely) dated 8/12/25 after surveyor inquiry.On 8/13/2025 at 11:39 AM, the surveyor reviewed physician orders for the month of March 2025 which revealed an order dated 3/20/25 for an appointment with a pulmonologist within one month.Further review revealed an order dated 3/20/25 to a follow-up CT scan in July 2025. On 8/13/2025 at 11:50 AM, the surveyor interviewed the Director of Nursing (DON), who stated, that she had to look back and see why the appointment was cancelled. The DON further stated that the pulmonologist came into see the resident twice and the resident was not in their room. On 8/13/25 at 1:57 PM, the surveyor met with the licensed Nursing Home Administrator (LNHA), DON Regional VP of Clinical Services to review the above concern. The DON stated that the resident had an appointment on March 25, 2025, but did not know what for. The DON further stated that she spoke to the Nurse Practitioner, who stated that they came into see the resident, but the resident was not in their room. The DON confirmed that there was no documentation in the residents' medical records as to why the follow up appointment with the Pulmonologist and the CT scan was not done. On 8/14/2025 at 1:06 PM, the Team Coordinator met with the LHNA, DON, VP of Clinical Services and they acknowledged that there was no documentation that the pulmonologist came twice to see the resident. The administration also stated that the pulmonologist said she told the facility when she came but the resident was not available and was not documented in the residents' medical records. The Administration also acknowledged that there was no documentation why the CT scan was not done at the time that it was ordered.On 8/13/2025 at 1:20 PM, the surveyor reviewed the facility policy titled, Provision of Physician Ordered Services, dated 9/1/24, which revealed: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. A review of the facility policy titled, Policy Explanation and Compliance Guidelines revealed: #2 Qualified nursing personnel will submit timely requests for physician ordered services ( .radiology, consultations) to the appropriate entity.NJAC 8:39-27.1(a)

Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to ensure, a.) proper handling and storage of linen and laundry and b.) proper disposal of garbage to prevent the potential spread of infection in accordance with standards of clinical practice, and the facility's policy. This deficient practice was identified for 1 of 1 laundry area, 1 of 3 linen rooms, and 1 of 2 shower rooms observed during infection control tour.This deficient practice was evidenced by the following:On 8/13/25 at 9:38 AM, the surveyor toured the laundry area in the presence of the Laundry Staff (LS). Both the surveyor and the LS observed the following:-Upon entry to the laundry area, there was an electric fan on the floor blowing air toward the clean hung personal clothes of the residents. The electric fan with heavy accumulation of grayish substances and the personal clothes of the residents were uncovered. The LS confirmed that it was accumulation of dust that was in the electric fan and should have been cleaned.-the laundry floor with scattered crumpled papers, candy wrappers, and accumulation of dust. The LS confirmed the observation and stated that the floor did not look like it was mopped last night. The LS further stated that she did not know when the last time was it was mopped.-the laundry folding table for clean clothes with bottled water (halfway full), lunch bag, papers, binder, pens, notebook, roll of plastic bags, hangers, personal bottle container, and a clean sock with room number that was handwritten over a piece of tape. The LS confirmed that there should be no personal stuff on top of clean folding table that was being used for folding the clean clothes of the residents.- there was an electric heater upon entry to the door on the ceiling with heavy accumulation of grayish substances which the LS considered dust and should have been cleaned.- there was a commercial electric fan on the end of the room was blowing air toward the clean unfolded clothes of the residents. The commercial electric fan with accumulation of grayish substances that the LS confirmed dust and should have been cleaned. The LS stated that there was no window in the laundry room and needed the fan, there was a clean residents clothing uncovered near the commercial fan and the LS stated that was contaminated now.On 8/13/25 at 9:48 AM, the surveyor and the Housekeeping Director (HD) went inside the clean linen room, upon entry there was an electric fan with heavy accumulation of grayish substances, blowing air toward the clean folded linens, blankets, towels, and gowns. The linen supplies were uncovered and unbagged. There was a used surgical mask on the floor. The floor with accumulation of dust (grayish substances). There were three ceiling tiles with dried brownish discoloration and below were clean folded fitted sheets uncovered and unbagged.On that same date and time, the HD stated that the brownish discoloration on the ceiling tiles was water condensation. She further stated that fan should have been cleaned, no garbage on the floor, and the clean folded linens were now considered contaminated due to accumulation of dust that were blown to the clean supplies. The HD also stated that the surgical should be properly disposed to the garbage receptacles and not left on the floor.On 8/13/25 at 9:55 AM, the surveyor with the HD toured the 3rd floor shower room and both observed the 2nd cubicle shower there was a wet used washcloth on the floor. The HD stated that it was the CNA who used the washcloth for cleaning the resident and should not be on the floor. The HD acknowledged that the used washcloth should have been properly disposed to the garbage receptacle. On 8/13/25 at 11:05 AM, the surveyor interviewed the Infection Preventionist Nurse/Licensed Practical Nurse (IPN/LPN) in the presence of the Regional Registered Nurse (RRN). The IPN/LPN informed the surveyor that part of her responsibility as an IPN was to do environmental rounds. The surveyor notified the IPN/LPN and the RRN of the above findings and concerns. The IPN/LPN acknowledge the surveyor's concerns. The IPN/LPM and the RRN had no response when asked by the surveyor why the above findings and concerns were not identified if that was part of the IPNs responsibility to do infection control routine tour. On 8/13/25 at 1:49 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), [NAME] President of Clinical Services (VPoCS), and the surveyor notified them of the above observations, concerns and findings with regard to infection control. A review of the facility's Handling Clean Linen Policy that was provided by the VPoCS, with date of implementation of 9/1/24, revealed that it was the facility's policy to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection .Definitions: linen includes sheets, blankets, pillows, towels, washcloths, and similar items from departments such as nursing, dietary, rehabilitative services, beauty shops, and environmental services. contaminated linen is linen that has been soiled with blood or other potentially infectious materials .Policy Explanation and Compliance Guidelines: 2. Linen can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands .5. Guidelines for the storage of clean linen include, but are not limited to, the following: a. Nothing shall be kept on top of linen carts. Only rolls of bags used for linen transport m ay be kept on the carts, in the designated pockets only.On 8/14/25 at 1:06 PM, the survey team met with the LHNA, DON, and VPoCS, and the LNHA stated that all vents were cleaned after surveyor's inquiry and staff were educated. The LNHA further stated that was always the expectation the vents would be cleaned.NJAC 8:39-19.4(a),l

Complaint #NJ 165064 Complaint #NJ 166666 Based on interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to 1.) provide adequate supervision for a cognitively impaired, exit seeking resident and ensure exit doors were securely locked which resulted in Resident # 353 eloping from the facility on 06/15/2023 and 2.) follow facility elopement policy which resulted in Resident # 355 eloping from the facility on 08/17/2023. This deficient practice was identified for 2 of 3 residents (Resident # 353 and Resident # 355) reviewed for elopement. The facility failed to monitor and supervise a cognitively impaired, exit seeking resident from being able to exit the facility through an unsecured exit door. This posed a serious and immediate risk to the health, safety, and well-being of Resident #353. During an annual Recertification survey on 04/19/24, the survey team identified an Immediate Jeopardy (IJ) running from 06/15/23 at 8:53 PM, when the resident eloped from the facility, to 06/15/23 at 9:05 PM, when the resident was found. The Immediate Jeopardy (IJ) situation was determined to have existed on 06/15/2023, when Resident #353 exited the building without staff knowledge and was found by facility staff several blocks away from the facility, adjacent to a wide, double-lane roadway. The facility developed and implemented a corrective action plan, and the past-noncompliance IJ was determined to have been removed on 06/15/2023. The facility's noncompliance was corrected on 06/16/2023. On 04/19/2024 at 2:39 PM, the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and regional staff were informed of the past non-compliance IJ situation. This deficient practice was evidenced by the following: Part A 1. Review of a facility policy with a review date of 6/2023 titled, Elopement indicated under Policy Interpretation and Implementation, section l . Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. The surveyor reviewed the electronic medical record (EMR) for Resident #353 which revealed the following: Review of the Admission Record for Resident #353 included diagnoses but were not limited to; encephalopathy (a broad term for any brain disease that alters brain function or structure), epilepsy (a seizure disorder), and schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). Review of a Comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/19/23, reflected the resident had a brief interview for mental status (BIMS) score of 0 out of 15, indicating that the resident had severe cognitive impairment. Review of a Quarterly Minimum Data Set (MDS) dated [DATE], reflected that the facility documented the resident was rarely/never understood and testing for a BIMS score was not performed. Review of a Quarterly Minimum Data Set (MDS) dated [DATE], reflected the facility documented under section G that the resident was able to Locomotion off unit-how resident moves to and from distant areas on the floor 2. Limited assistance 2. One person physical assist. A review of the physicians' orders revealed there were no physician orders for wandering or elopement risks for Resident #353. Review of an elopement risk assessment dated [DATE], indicated the resident scored a 7 upon the assessment, indicating the resident was a low risk for elopement. Review of a nursing progress note (PN) dated 5/17/23, documented that Resident # 353 was wandering in the unit hallway stating they wanted to go home. The PN further indicated the resident's family member was present and the resident was redirected by staff. Review of a PN dated 6/12/23 at 5:12 AM, documented the resident was found waiting around the lobby stating they were getting ready to go downtown. The resident was returned to their unit and would be monitored for exit seeking. Further review of the PNs, revealed documentation dated 6/15/23 at 1:53 PM, indicating that Resident #353 was alert and confused, ambulating up and down the unit hallway. Resident #353 had to be redirected from entering the elevator and was stating, I have to go home today. Review of the comprehensive care plan (CP) for Resident #353 initiated on 6/15/2023 indicated, At risk for elopement related to: Resident states 'I am leaving, going home'. The documented interventions in the CP included: involving the resident in preferred activities, involving resident in decision making regarding daily choices, redirecting the resident from doors, shift to shift endorsement to visually monitor resident especially during shift changes or when the resident talks about going home, involving family when the resident starts to verbalize desire to go home by having them call or visit (frequently when possible), encourage family to bring in personal possessions, and evaluate the effect of cognitive impairment with the resident's ability to understand changes in surroundings. Review of a PN dated 6/15/23 at 11:34 PM documented the following: -At 4:10 PM, Resident #353 was calm and seen sitting in the lobby downstairs. -At 5:00 PM, the assigned Licensed Practical Nurse (LPN) #5 received a call from the third-floor unit manager that the resident wanted to go home and did not want to return upstairs. The resident's family members were called and stated they would come to see the resident. The resident then agreed to return to their room. - At 7:00 PM, the resident's family members came, visited with the resident, and left the resident in their room. - At 8:00 PM, LPN #5 received a call from the receptionist that the resident was downstairs in the lobby. The receptionist escorted Resident #353 back to the unit and the resident was provided a snack. The resident was left in their room and did not verbalize to staff needing anything else. - At 8:53 PM, LPN #5 received a call from the front lobby that the resident had left the facility, code gray was initiated and the staff searched for the resident. - At 9:05 PM the resident was found near the facility sitting upright in no acute distress. The nursing staff stayed with Resident #353 until emergency medical services (EMS). The resident was sent to the hospital emergency room (ER) for a complete evaluation. A PN dated 6/16/23 at 6:47 AM documented the resident was admitted to the hospital with a diagnosis of hyponatremia. Resident #353 did not return to the facility. A review of an investigation report completed by the facility indicated that Resident #353 had an actual elopement on 6/15/23 at 8:53 PM, and the investigation revealed the following: At 8:53 PM, Resident #353 was observed by a housekeeping staff exiting the ground kitchen door from their view from the 2nd floor balcony. The housekeeping staff ran downstairs to inform the front desk. The facility's elopement protocol-code gray was initiated, and staff started to search for the resident. At 9:05 PM, Resident #353 was found sitting near the facility, staff stayed with the resident until EMS arrived and brought the resident to the hospital for further evaluation. The resident was uninjured during initial assessment by facility staff and was admitted to the hospital with a diagnosis of hyponatremia. A review of a written statement dated 6/15/23, documented by LPN #5 indicated the location of where Resident #353 was found which was several blocks away from the facility adjacent to a wide, double lane roadway. Interventions listed at time of the elopement included: An investigation and a search were initiated. The police were called at time of elopement. Immediate in-service education with the facility staff regarding elopement was initiated. An employee was assigned to guard the exit door. The summary and conclusion of the investigation included: The resident exited through the side kitchen door. The resident was a low risk for elopement, a score of 7, based on the 1/12/23, elopement assessment completed. The investigation further documented, The door is [NAME] locked (a type of door lock that uses magnetism to secure a barrier) but a staff member deactivated the alarm system to access the dumpster area thus allowing the resident to leave the facility. The elopement was reported to the New Jersey Department of Health and the Ombudsman's office the day of the incident. On 4/18/24 at 11:56 AM, the surveyor interviewed the DON about the elopement of Resident #353. The DON stated it was believed the door was not closed properly which left the door unsecured and the resident was able to exit the facility. The DON stated there was no camera footage and could not identify the last staff member who used the exit door. The DON explained that the exit door was used by kitchen staff to access the loading dock and dumpster area. On 4/18/24 at 1:40 PM, the survey team met with the LNHA, DON, and regional staff. The surveyor informed the facility of the concern for the unsecured door and the resident exhibiting exit seeking behavior. The LNHA stated that the alarmed and [NAME]-locked exit door was believed to have malfunctioned, which led the exit door to remain unlocked and not alarm at the time of the elopement. The LNHA confirmed that there was no camera footage, and he could not determine which staff member last used the exit door prior to the resident's elopement. The LNHA added that there was 24-hour receptionist staff in the lobby. On 4/19/24 at 8:48 AM, the surveyor interviewed Receptionist #1 who was working in the lobby on the shift of the resident's elopement. Receptionist #1 stated that he recalled the resident was in the lobby in the afternoon prior to the elopement. Receptionist #1 could not recall the specific time and stated the resident was assisted back upstairs to their room. Receptionist #1 stated for the actual elopement he recalled someone coming to the front desk informing him that the resident left the facility, and he called to inform nursing staff. A code gray was called and the search for the resident began. On 4/19/24 at 12:15 PM, the surveyor interviewed the Maintenance Director who stated there were no known issues with the kitchen exit door prior to Resident #353's elopement. On 4/19/24 at 2:39 PM, the survey team met with the LNHA, DON and regional staff about the elopement of Resident #353 and informed them of the IJ past non-compliance. The survey team informed the facility that the failure to ensure a secure door remained locked and provide supervision to Resident #353, who exhibited exit-seeking behaviors, led up to the actual elopement on 6/15/23, resulted in an IJ situation. On 4/22/24 at 9:30 AM, the facility provided a copy of their corrective action plan that was developed and implemented beginning 6/15/23, after Resident #353 eloped from the facility. Review of the plan revealed the following actions taken on 6/15/23: .Door noted to malfunction on 6/15/23. 24 hr. door monitor initiated . Elopement and wandering residents' policy was reviewed . In-service education with all staff on Identification of Residents at Risk for Elopement, Elopement and Wandering policies . Daily door checks initiated daily x 2 weeks and weekly thereafter . The plan further indicated ongoing education to staff regarding elopement precautions and policies, keypad access doors and door safety education, weekly inspection of exit doors and function; Quality assurance performance improvement project to review and interpret all audit findings. After conducting observations, interviews, record review and review of pertinent documents, the survey team verified the facility implemented all components of the action plan and the deficient practice was corrected on 6/16/23, prior to the annual survey entrance. On 4/22/24 at 11:26 AM, the surveyor conducted a telephone interview with LPN #5 who stated Resident #353 was alert with periods of confusion, able to verbalize their needs, and ambulated independently. LPN #5 stated for wandering and elopement risk residents, interventions included keeping exit doors secured, encouraging recreational activity, performing visual observations of the resident. LPN #5 further stated that in the afternoon prior to the resident's elopement she received a call from the unit manager at the time that the resident was in the lobby and wanted to go home. LPN #5 explained she called the resident's family member who came to visit the resident and the resident agreed to stay at the facility. LPN #5 further stated she could only recall later that evening she received a phone call from Receptionist #1 who reported that the resident left the facility. She further explained a code gray was called and the search for the resident was initiated expanding outside the facility. The LNHA, DON, ADON, physician, the resident's family member and police were called and made aware of the resident's elopement. LPN #5 stated the resident was found by staff not far from the facility. The resident was unharmed. 44605 Part B 2. On 4/15/24 at 12:58 PM, the surveyor reviewed the Facility Reported Event (FRE), which revealed Resident #355 had eloped from the facility on 8/17/23, and did not return to the facility due to Resident #355 being arrested during the elopement. On 4/15/24 at 1:15 PM, the surveyor reviewed the Admission Record (AR) for Resident #355 which reflected the resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to bipolar disorder, displaced segmental fracture of shaft right tibia and displaced fracture of proximal phalanx of left thumb. A review of the Admission MDS dated [DATE], indicated the resident had a BIMS score of 15, indicating Resident #355 was cognitively intact. A review of the Order Summary report included a discontinued physician's order dated 8/13/2023, which indicated, Resident can go out on pass with responsible party from 8 AM to 8 PM. A review of Resident #355's care plan listed under the intervention section stated, Out of pass (OOP) order discontinued (d/c), privileges were removed with an initiated date of 8/14/2023. On 4/16/24 at 12:10 PM, the surveyor reviewed the facility investigation report provided by the Director of Nursing (DON). The facility investigation report revealed that on 8/17/23 at 7:15 PM, Resident #355 told the front desk receptionist he/she has going outside to smoke and then would be going OOP. The receptionist did not verify with the nursing staff that Resident #355 was going OOP. At 8 PM during the medication pass, it was discovered Resident #355 eloped when his/her wheelchair was found in the front lobby. A search of the facility property was conducted, and the resident was not located. The [NAME] police were contacted and informed of the issue. Facility staff were able to contact Resident #355 on their cell phone and the resident stated he/she was at the [name redacted] in [NAME] dealing with a family issue and would return to the facility at 3:00 AM. At 3:20 AM, the staff attempted to contact Resident #355, but their phone went directly to voicemail. At 7:00 AM on 8/18/23, a [NAME] Police Officer arrived at the facility and informed the staff that they would go to the [name redacted] and return with Resident #355. Resident #355 was arrested due to an outstanding warrant and did not return to the facility. On 4/16/24 at 01:04 PM, the surveyor conducted an interview with the DON who stated the front desk receptionist should not have let Resident #355 outside to the first floor patio to smoke because all smoking is supposed to take place on the second floor patio as per their policy. The receptionist should have also confirmed the OOP with the nursing staff on the unit as per the facility policy. The DON confirmed that Resident #355 OOP privileges had been discontinued on 8/13/23, related to a previous issue and the receptionist should have been informed of Resident #355 OOP status. On 4/18/24 at 11:30 AM, the surveyor interviewed the 4th floor Registered Nurse Unit Manager (RN/UM). The RN/UM stated when a resident's OOP privileges are suspended or discontinued, the facility has a team meeting to discuss the concern, the social worker meets with the resident to alert them of their OOP status, the receptionist is alerted, and the resident's picture is added to the elopement risk sheet located at the front desk. On 4/18/24 at 12:47 PM, the surveyor interviewed Receptionist #2, who stated the OOP procedure is as follows, when a resident comes to the receptionist desk to go OOP, we call their unit to confirm they are allowed to go OOP. The resident and responsible party sign out in the logbook and sign in upon return. The surveyor asked if a resident had their OOP privileges suspended are you alerted? Receptionist #2 stated, In that event we are alerted by the administrator, director of nursing or the social worker that a resident cannot go out on pass and their picture is added to the elopement risk list. Receptionist #2 was asked if residents can smoke in the front on building? Receptionist #2 stated, any residents who are smokers go out on the second floor, which is the designated smoking area. On 4/19/24 at 09:05 AM, the surveyor interviewed the Social Worker (SW) who stated Resident #355 was made aware of their OOP privileges are suspended and understood why without issue. Resident #355's photo was added to elopement list at the reception desk. On 4/17/24 at 12:20 PM the Regional Director of Clinical Services (RDCS) provided with surveyor with facilities policies titled, Smoking Policy - Residents, Staff and Visitors and Out on Pass Policy with a revision date of 10/2023. The smoking policy indicated under the policy interpretation and Implementation, 1. Prior to admission and upon entry, Residents, Staff and Visitors shall be informed of the facility smoking policy, including designated smoking areas, times for residents and the extent to which the facility can accommodate their smoking or non-smoking preferences. Review of the Out of Pass policy indicated under the procedure 6. Upon leaving the facility, the resident/responsible party will inform the Change Nurse and sign out on pass; 8. The resident/responsible party must sign in and out at the lobby desk; and 10. The nurse will notify security if a pass is rescinded. On 4/19/24 at 11:52 AM, the survey team met with the Licensed nursing Home Administrator (LNHA), the DON, the RDCS and [NAME] President of Operations (VPO) to discuss the above concerns. The LNHA stated there was a breakdown in communication and facility policies with regards to Resident #355 elopement and in-services will be conducted. There was no further information provided. NJAC 8:39-33.1(d)

Based on observation, interview, record review and review of facility documents, it was determined that the facility failed to adhere to acceptable standards of nursing practice. This deficient practice was identified in 4 of 7 residents who had medication improperly prepared for administration, 1. Resident #86, #199, #73, #200, 2. facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 1 of 3 Residents reviewed for accurate dialysis scheduling of medication times, Resident #84, 3. failed to ensure that the oxygen rate was administered according to Physician's Order (PO), for 1 of 1 Residents reviewed for Oxygen use, Resident #2 4. facility failed to ensure recommendations made by the Registered Dietician was acted upon in a timely manner as per facility policy and in accordance with professional standards of clinical practice for one (1) of two (2) residents reviewed for tube feed, Resident #122. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 4/15/24 at 1:01 PM the surveyor entered the 3rd Floor medication room. The surveyor observed the Licensed Practical Nurse (LPN) #2 standing by her medication cart with a stack of medication cups on top of the cart. Closer examination by the surveyor of the medication cups revealed 4 stacked cups all with medication in them. Examination of each cup with LPN#2 revealed that each cup had the resident's first name written on each cup except the bottom cup, which had no name written on it. The surveyor requested that LPN#2 identify the resident and what was in the medication cup. LPN#2 could not identify the residents or the medication in the cup without referring to the electronic medication administration record (eMAR). Along with LPN#2 each cup was examined and identified: Cup 1 was identified as belonging to Resident #86 and contained 3 tablets of Hydralazine 25mg (an antihypertensive medication). Cup 2 was identified as belonging to Resident #199 and contained 1 tablet Depakote 25 mg (an antiseizure and mood stabilizing medication). Cup 3 was identified as belonging to Resident # 73 and contained 2 tablets of Methadone 10 mg (a controlled substance used for pain relief). Cup 4 was identified as belonging to Resident # 200 and contained 3 tablets of Depakote 250 mg (mood stabilizing medication). Review of the Individual Patient Controlled Substance Administration Record (Inventory Sheet) for Methadone 10mg tablets with LPN#2 revealed that there were 46 tablets left in stock. Examination of the actual inventory of Methadone 10 mg tablets in stock was 44 tablets. The surveyor interviewed LPN#2 who stated, I didn't give it yet. LPN#2 was not aware that the Inventory Sheet needed to be signed out for the tablets removed from inventory at the time of the removal. The surveyor continued the interview with LPN#2 who could not explain why she prepared the medications for 4 residents in advance, instead of individually preparing and administering medication to each resident. LPN#2 stated that she knows that this was not best practice. The surveyor reviewed the facility hybrid documents: A. Review of the facility Admission Sheet for Resident #86 revealed that the resident was admitted to the facility with diagnoses which included but were not limited to Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension, Chronic Kidney Disease and Diastolic Heart Failure. A review of Resident #86's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/29/24, reflected that Resident #86 had a BIMS score of 15 out of 15, indicating an intact cognition. The surveyor reviewed the April 2024 eMAR which documented a Physician's order (PO) dated 10/29/23 for Hydralazine 25 mg Give 3 tablets by mouth every 8 hours for Hypertension. B. Review of the facility Admission Sheet for Resident #199 revealed that the resident was admitted to the facility with diagnoses which included but were not limited to Seizures, Adjustment Disorder with Anxiety, and Other Psychoactive Substance Induced Disorder. A review of Resident #199's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/31/24, reflected that Resident #199 had a BIMS score of 8 out of 15, indicating a moderately impaired cognition. The surveyor reviewed the April 2024 eMAR which documented a Physician's order (PO) dated 11/3/23 for Depakote Tablet Delayed Release 125 mg 1 tablet 3 times daily for convulsion. C. Review of the facility Admission Sheet for Resident #73 revealed that the resident was admitted to the facility with diagnoses which included but were not limited to Other Psychoactive Substance Abuse, Complicated, Adjustment Disorder with Anxiety, and Acquired absence of right and left leg above the knee. A review of Resident #73's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/19/24, reflected that Resident #73 had a BIMS score of 15 out of 15, indicating an intact cognition. The surveyor reviewed the April 2024 eMAR which documented a Physician's order (PO) dated 11/27/23 for Methadone 10 mg Give 2 tablets by mouth 3 times a day for pain. D. Review of the facility Admission Sheet for Resident #200 revealed that the resident was admitted to the facility with diagnoses which included but were not limited to Epilepsy, Schizophrenia, and Mood Disorder. A review of Resident #200's Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/11/24, reflected that Resident #200 had a BIMS score of 9 out of 15, indicating a moderately impaired cognition. The surveyor reviewed the April 2024 eMAR which documented a Physician's order (PO) dated 3/29/24 for Depakote Delayed Release 250 mg Give 3 tablets 3 times daily for Schizophrenia. Review of the facility Administering Medications Policy explains, Medications shall be administered in a safe and timely manner, and as prescribed. The policy continues to explain, 4. The individual administering medications must verify the resident's identity before giving the resident his/her medications. and 5. The individual administering the medication must check the label against the Physician's order to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of the facility Documentation of Medication Administration Policy explains, 4. When giving controlled subtance when removed from the lock box, it must be signed on the declining sheet. Once administered it must be signed on the eMAR. On 4/15/24 at 1:45 PM, the surveyor discussed the above deficient practice with the Director of Nursing (DON) and the Assistant DON who could not explain why LPN#2 prepared the medication for Resident #86, #199, #73 and #200 in a stack of cups. The DON stated that this is not the proper way to administer medication to residents in the facility. The DON added that all medications administered to a resident should be reviewed, administered, and documented, one resident at a time. The DON commented that LPN#2 should not have prepared medication for a number of residents and should have known to sign out narcotics from the inventory sheet when she removed the narcotic medication from inventory. 39399 2. On 04/16/24 11:29 AM, the surveyor observed that Resident #84 in bed, awake and alert. A review of the facility Admission Sheet for Resident #84 revealed that the resident was admitted to the facility with diagnoses which included but were not limited to End Stage Renal Disease, Anemia, Benign Prostatic Hypertrophy, Dependence on Renal (kidney) Dialysis and Dementia. A review of Resident #84's Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate management of care, dated 3/31/24, reflected that the resident had a Brief Interview Mental Status (BIMS) score of 12 out of 15, which indicated that the resident had moderate cognitive impairment. A review physician's orders for April 2024 read: HEMO-DIALYSIS THREE TIMES WEEKLY ON (TUES, THURSDAY, SATURDAY 6:30 AM) at [dialysis center's name, address and telephone number] pick up at 5:45 AM by [Transportation company's name and telephone number]. A physician's order dated 12/23/23 read: Calcium Acetate tab (tablet) 667mg (milligrams) give 2 tabs (tablets) by mouth three times a day every TThS (Tuesday, Thursday, Saturday) timed at 9:00 AM, 1:00 PM and 5:00 PM. A review of the January 2024 electronic Medication Administration Record (eMAR) revealed that the resident was scheduled to receive the Calcium Acetate medication as ordered above every TThS at 0900 [9 AM]. The entries for 1/4/24, 1/6/24, 1/23/24 and 1/27/24 were signed by the nurses with 7 which indicated Other/See nurses notes and that the medication was not administered. A review of the February 2024 eMAR revealed that the resident was scheduled to receive the Calcium Acetate medication as ordered above every TThS at 0900 [9 AM]. The entry for 0900 on 2/7/24, was signed by the nurse with 7 which indicated Other/See Nurse Notes, and on 2/17/24 was signed by the nurse with 3 which indicated Hold/See Nurse Notes and that the medication was not administered. A review of the March 2024 eMAR revealed that the resident was scheduled to receive the Calcium Acetate medication as ordered above every TThS at 0900 [9 AM]. The entry for 0900 on 3/7/24, 3/9/24, 3/12/24, 3/14/24, was signed by the nurse with 7 which indicated Other/See Nurse Notes, and on 3/30/24 was signed by the nurse with 3 which indicated Hold/See Nurse Notes and that the medication was not administered. A review of the nurses' progress notes in the Electronic Medical Record (EMR) revealed that the medication was not administered on the entries identified above as the resident was out to dialysis during the medication administration time. On 4/19/24 at 2:38 PM, the surveyor discussed the above concern to the facility's the Licensed Nursing Home Administrator (LNHA), the [NAME] President of Operations (VPO), the Director of Clinical Services (DCS), the Regional Registered Nurse (RRN), the Director of Nursing (DON), Assistant DON. The DON stated that the facility's protocol for medications to be scheduled to accommodate resident when they are out for dialysis. The facility's DON, VPO, RRN acknowledged that the medication should have been scheduled to accommodate the resident dialysis schedule. A review of the facility's policy titled Hemodialysis , did not reveal anything related to medication timing to ensure that medications are times with the dialysis days/schedule of the resident. 3. On 04/15/24 12:10 PM, the surveyor observed Resident #2 seated in their wheelchair. The surveyor further observed that the resident was on continuous oxygen via nasal canula with the rate set at 8 liters/minutes. The resident was Spanish speaking. A review of the facility Admission Sheet for Resident #2 revealed that the resident was admitted to the facility with diagnoses which included but were not limited to Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hypertension and Parkinsonism. A review of Resident #2's Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate management of care, dated 1/19/24, reflected that the resident had a Brief Interview Mental Status (BIMS) score of 8 out of 15, which indicated that the resident had moderate cognitive impairment. A review of the physician's order dated 4/8/24 revealed a PO for Oxygen at 2 l/min (liters/minute) via nasal cannula continuously. On 4/15/24 at 12:35 PM, the surveyor interviewed the 3rd floor Unit Manager (UM)/LPN #2 who confirmed that the PO for oxygen was to be administered at the rate of 2 l/min. The UM/LPN #2 in the presence of the surveyor went inside the resident's room. The UM/LPN #2 stated to the surveyor that the resident was on oxygen rate set at 8 l/min. On 4/15/24 at 12:41 PM, the surveyor in the presence of another surveyor who speaks Spanish interviewed Resident #2. The resident stated in Spanish that he/she does not touch the oxygen to change the flow rate. On 4/15/24 at 12:48 PM, the surveyor interviewed LPN #3 assigned to Resident #2 who stated that he checked the oxygen including the rate set of every resident in the morning during the beginning of his shift at 7:00 AM and before the end of the shift at 3:00 PM. On 4/19/24 at 2:38 PM, the surveyor discussed the above concern to the facility's the Licensed Nursing Home Administrator (LNHA), the [NAME] President of Operations (VPO), the Director of Clinical Services (DCS), the Regional Registered Nurse (RRN), the Director of Nursing (DON), Assistant DON. There was no further information provided. 45449 4. On 4/15/23 at 12:59 PM, the surveyor observed Resident #122 seated in a geri-chair (a large, padded chair that is designed to help seniors with limited mobility), combed, and well dressed. The resident was conversant and stated that they felt well that day. The surveyor observed a bottle of Osmolite 1.5 (nutritional formula) hanging on an intravenous (IV) pole. The Osmolite 1.5 bottle had a light brown liquid remainder less than 200 milliliters (ml/s). The pump was off but was set to a rate of 65 and had delivered 985 milliliters at that time. The surveyor reviewed the hybrid medical record for Resident #122. A review of Resident #122's Admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to congestive heart failure (CHF; a chronic condition wherein the heart does not pump blood as well as it should), type 2 diabetes without complications (high blood sugar), dysphagia (difficulty or discomfort in swallowing) and gastrostomy status (resident with feeding tube). A review of Resident #122's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 3/31/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that Resident #122's cognition was severely impaired. Additionally, the MDS revealed that the resident was independent for eating. Review of the qMDS, Section K - Swallowing/Nutritional Status reflected the resident had a feeding tube and was on a therapeutic diet. Further review of the qMDS, dated [DATE], Section M - Skin Conditions indicated the resident was at risk of developing pressure ulcers and had no pressure ulcer for that review date. A review of the resident's wound assessment dated [DATE], indicated the resident had a stage 2 sacrum pressure ulcer that had reopened and was acquired on 4/9/24. A review of the Order Summary (physician orders) that were active as of 4/17/24, included the following: -Enteral feed order, every day shift document total ml infused; the order start date was on 4/10/24. -Enteral feed order, every evening shift for patency check tube for residual prior to continuous feeding. Of residual is greater than 100 ml, hold feeding for 1 hour and recheck. If residual is greater than 50 mls on recheck, notify MD; the order start date was on 4/14/24. -Osmolite 1.5 at 65ml/hr (per hour) via gastrostomy tube (g-tube), up at 4:00 PM and infused until total volume (TV) of 1300 ml is infused, providing 1950 kcal/day (kilo calorie per day), 82 g (gram) of PRO (protein); the order start date was on 4/10/24. -Enteral Feed Order six times a day for patency, provide water flushes via PEG-tube (percutaneous endoscopic gastrostomy; feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall) of 155 ml 6 times a day; the order start date was on 2/6/24. -Monthly weight;the order was started on 1/26/24. A review of the Registered Dietician's (RD), Nutrition Progress Note (NPN) dated 4/10/24, included the following recommendations: - Resident #122 was noted with vomit on 4/9/24. - Trial of Osmolite for tolerance, monitor blood glucose/A1C (a blood test that reveals the average blood sugar over the past two to three months) - Osmolite 1.5 via PEG continuous at 65 ml/hr, TV 1300ml with free water of - 15 g of PRO from Prostat (protein supplement) - 150 ml of free water flush from 150ml 6 times per day an additional of 900 ml - Weekly weights for 2 weeks. The RD also documented that the family was made aware of the TF changes. A review of the resident's weights reflected the following: -4/17/24, 161 pounds via mechanical lift -4/10/24, 160 pounds via mechanical lift -3/4/24, 161 pounds via mechanical lift -2/14/24, 159 pounds via mechanical lift -1/15/24, 164 pounds via mechanical lift -1/9/24, 164 pounds via mechanical lift During an interview with the surveyor on 4/17/23 at 11:08 AM, the RD stated he reviewed the medical record for Resident #122 and made recommendations based on diagnosis, laboratory results, weights, therapeutic diet needs, hospital records, the resident's wishes, familial consent, and collaborated with nurses, physicians and other health care ancillary involved with the resident. At that time, the RD confirmed his recommendations for the decrease of free water to 150 ml six (6) times a day (for flushing and hydration), and the new order for Prostat (a protein supplement used to promote wound healing related to the stage 2 sacral pressure ulcer that had reopened on 4/9/24) were not part of the active orders on 4/17/24. The RD was unsure why it was not part of the active orders or of it the recommendation was missed. On 4/17/24 at 11:54 AM, during an interview with the surveyor, the Regional Registered Dietician (RRD) explained the process for recommendations made. The RRD stated that the recommendations were entered into the electronic Medical Record (eMR) as pending, then validated by a nurse and when the medical doctor (MD) or the nurse practitioner (NP) agreed, the order was changed from pending to an active order. At that time, the RRD clarified that if the MD or the NP did not agree with the recommendation, the RD would have entered a follow-up NPN documenting the recommendations were not followed. At that time, the RRD confirmed that there were no documented follow-up NPN for the recommendation of the 150ml free water six times a day and the Prostat order. At that time, the RRD acknowledged the recommendations should have been acted upon. A review of the facility policy provided Consults/Recommendation Policy with a copyright date of 2024 included the following: Policy: The attending physician shall authenticate orders for the care and treatment of assigned residents. Policy Explanation and Compliance Guideline: 1. Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician .A consulting physician/practitioner may include, but is not limited to, a resident's .e. Nurse Practitioner, clinical nurse specialist, dietitian, or physician assistant to any of the above physicians. 2. For consulting physician/practitioner orders received in writing or via fax in a timely manner will: a. Call the attending physician to verify the order. b. Will confirm order in EMR system. c. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, transcribing to medication or treatment administration record. 3. For consulting physician/practitioner orders received via telephone the nurse will: a. Document the order on the physician order or EMR system, notating the time date name and title of the person providing the order, and the signature and title of the person receiving the order. b. Call the attending physician to verify the order. c. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, transcribing to medication or treatment administration record. On 4/18/24 at 1:36 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), the [NAME] President of Operations (VPO), the Director of Clinical Services (DCS), the Regional Registered Nurse (RRN), the Director of Nursing (DON), Assistant DON and the concerns regarding the RD recommendations were discussed. At that time they confirmed the process was that the recommendations should have been entered as pending and it was not. No further information was provided. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain infection control practices to reduce the risk of infection during a pressure ulcer (PU) treatment; b.) to assess a resident for risk for pressure ulcer quarterly and c.) ensure a physician's order was administered as ordered consistently for preventative measures for skin for 1 of 2 residents (Resident #25) reviewed for PU/injury. This deficient practice was evidenced by the following: On 4/15/24 at 11:44 AM, the surveyor observed Resident #25 asleep in bed with resident's daughter at the bedside. The surveyor interviewed Resident #25's daughter who stated that the resident had a PU, and that the PU was getting better. Resident #25's daughter further stated that the staff turned and changed the resident. On 4/18/24 at 9:56 AM, the surveyor observed the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #1 perform Resident #25's PU treatment. The ADON and LPN #1 performed hand hygiene (HH) with an alcohol based hand rub (ABHR) prior to donning (put on) a gown and gloves. The ADON and LPN #1 did not perform handwashing prior to the start of the PU treatment. Later in the PU treatment, the ADON removed the dressing on Resident #25's sacrum. The ADON removed her gloves and performed HH with ABHR and donned a new pair of gloves. LPN #1 prepared 4 X 4 dressings with Normal Saline (NS) and handed the NS moistened 4 X 4 dressings to the ADON. The ADON placed her left gloved hand on Resident #25's right buttock and left her hand on the buttock while the ADON used her right gloved hand to wipe the area around the PU with the moistened 4 X 4. The ADON then repeated the process with a new moistened 4 X 4 that LPN #1 handed to her, while her left hand remained on the resident's right buttock. The ADON then cleaned the PU with a new moistened 4 X 4 that LPN #1 handed to her with her right gloved hand while her left gloved hand remained on the resident's buttock. The ADON then repeated the process again with a new moistened 4 X 4. LPN #1 then removed a piece of foam gauze that was not a full piece and was previously cut from an already opened package. LPN #1 then cut a small piece of the foam gauze and placed Santyl ointment on the foam gauze with a tongue depressor and handed it to the ADON's right gloved hand. The ADON whose left hand was still on the resident's right buttock then used her right gloved hand to place the foam gauze on the resident's PU. LPN #1 opened the border gauze dressing and with her gloved hand took the pen that was attached to her badge and dated the border gauze dressing. LPN #1 then handed the border gauze dressing to the ADON who placed the border gauze dressing over the foam dressing on Resident #25's sacral area. The ADON did not doff (to take off) gloves, perform HH and don a pair of new clean gloves after cleaning the PU and prior to applying the Santyl and foam dressing. The ADON and LPN #1 did not use a new sterile foam dressing for the placement of Santyl to the PU. At the end of the PU treatment the ADON and LPN #1 doffed their gown and gloves and performed handwashing with soap and water. The ADON and LPN #1 did not disinfect the over the bed table that was used for the PU treatment. At approximately 10:42 AM, the surveyor interviewed the ADON regarding the PU treatment. The ADON confirmed that the foam dressing was not a new unopened packaged and that it had been opened and pieces cut from it for prior treatments. She added that the foam dressing was a large piece and that they cut a small piece to fit the size of the PU at each PU treatment for that resident. The ADON stated that she did not have to change her gloves after she cleaned the PU if the gloves were not visibly soiled. The ADON stated that she should have wiped the table after the PU treatment was done. A review of Resident #25's Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anemia, (condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), Type 2 diabetes mellitus with hyperglycemia (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel with elevated blood sugars) and severe protein-calorie malnutrition (state of inadequate intake of food (as a source of protein, calories, and other essential nutrients) occurring in the absence of significant inflammation, injury, or another condition that elicits a systemic inflammatory response). A review of Resident #25's electronic Progress Notes included a note dated 01/03/24 which included the following: The resident is being evaluated for new skin alteration to sacrum. A review of Resident #25's Significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/10/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 01 out of 15, which indicated that Resident #25's cognition was severely impaired. Further review indicated that the resident had one (1) unstageable PU that was not present on admission/entry or reentry. A review of Resident #25's December 2023 Treatment Administration Record (TAR) included the following order: Apply Zinc Oxide (used to treat or prevent minor skin irritations such as burns, cuts, and diaper rash) on sacrum every shift. The December TAR included 6 of 30 day shifts, 11 of 30 evening shifts and 6 of 30 night shifts that were blank which indicated the nurse did not sign that the zinc oxide was not administered. A review of Resident #25's electronic medical record indicated that the resident had a Braden Scale for Predicting Pressure Sore Risk (BSFPPSR) dated 3/17/23. Further review of the medical record did not include any quarterly BSFPPSR assessments for the rest of 2023. There was a Nurses Quarterly Assessment, which included the BSFPPSR, dated 4/10/24. There was not a BSFPPSR assessment done in January 2024. On 4/18/24 at 11:28 AM, the surveyor interviewed the UM/LPN 2nd floor unit regarding how often the BSFPPSR was done. The UM/LPN stated that they were done quarterly. On 4/18/24 at 12:24 PM, the surveyor interviewed LPN #1. LPN #1 stated that zinc oxide was used to prevent skin breakdown. She added that she was not sure why there was blanks on the TAR and what the blanks meant. On 4/18/24 at 12:31 PM, the surveyor interviewed UM/LPN 2nd floor unit regarding Resident #25's quarterly BSFPPSR. The UM/LPN stated that she did not know why the resident did not have the assessments and that she did not know why they were not triggered in the computer. On 4/18/24 at 12:33 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the Braden Scale was done on admission and quarterly and it was documented in the computer system under the assessment tab. The DON stated that if there were blanks on the TAR that it meant that it was not given. The DON stated that zinc oxide was a skin protectant. The DON stated that Handwashing should be done prior to a PU treatment and the table should be wiped after the treatment. The DON stated that he had to check what the policy had in regard to changing gloves. The DON stated that a piece of foam could be saved to use that same day for the same resident but that it should not be saved for another day. On 4/18/24 at 01:16 PM, in the presence of the survey team, the surveyor told the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), ADON, VP of Operations (VPoO) and Regional Nurse the concern regarding Resident #25's wound treatment, Braden Scale not done quarterly and the missing administrations of zinc oxide. On 4/19/24 at 11:53 AM, in the presence of the survey team, LNHA, DON and VPoO, the Regional Nurse stated that the staff were in serviced on the wound treatment including changing gloves, not cutting the foam, and wiping the table. She stated that the staff applied the zinc oxide but that they just did not document it. She added that the staff were in serviced. The Regional Nurse stated that the facility policy has HH, and that handwashing did not have to be done if the hands were not visibly soiled or the nurse was not in contact with C. difficile (Clostridioides difficile; a bacterium that causes an infection of the colon, the longest part of the large intestine and symptoms can range from diarrhea to life-threatening damage to the colon). A review of the facility provided policy titled, Wound Care with an updated date of 5/2023 included the following: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure: 2. Perform hand hygiene . 11. Wear clean gloves when physically touching the wound or holding a moist surface over the wound. 12. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with normal saline as ordered. 13. Remove dry gauze. Apply treatments as indicated. 14. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time and date and apply dressing. Be certain all clean items are on clean field . 19. Return the overbed table to its proper position. 20. Wipe reusable supplies with alcohol as indicated . A review of the facility provided policy titled, Assessment Frequency/Timelines with a copyright date of 2023, included the following: Policy: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. Policy Explanation and Compliance Guidelines: 4. A quarterly review assessment will be completed no less than once every 3 months On 4/19/24 at 01:23 PM, in the presence of the survey team, the Regional Nurse stated that Resident #25 did not have some of the quarterly Braden Scale assessments done. The facility did not provide any further information. N.J.A.C. 8:39-27.1

Based on observation, interview, and record review, it was determined that the facility failed to assure that the physician responsible for supervising the care of residents completed monthly progress notes. This deficient practice continued over several months for 5 of 31 residents reviewed, Resident #71, #142, #352, #138 and #63 reviewed for physician progress notes and current physician orders. This deficient practice was evidenced by the following: 1. On 4/15/24 at 11:36 AM, the surveyor observed Resident #71 sitting in a wheelchair in their room. The resident was lethargic and non-arousal. The surveyor reviewed the hybrid medical records of Resident #71 which revealed the following: Review of Resident #71 Admission Record (AR) reflected that Resident #18 was admitted to the facility with medical diagnoses that included but were not limited to major depression, schizophrenia, type 2 diabetes mellitus and heart failure. A review of Resident # 71's hybrid medical records revealed that from 6/4/21 to 1/26/24 the Primary Physician (Physician #1) had not written any monthly Medical Progress Notes (PN) in the electrotonic or paper chart. On 4/17/24 at 10:40 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor team with a facility policy titled, Physician Visits. with a revised date of April 2020. Under the policy interpretation and implementation section of the policy it states, 5. The Attending Physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. On 4/19/24 at 11:52 AM, the surveyor team met with the LNHA, Director of Nursing (DON), Regional Director of Clinical Services (RDCS) and [NAME] President of Operations (VPO) with discuss concerns. The RDCS stated the Physician #1 should be documenting on their residents at the time of visit, they have spoken the Physician # and provided an in-service on timely documentation. On 4/23/24 at 10:29 AM, the surveyor team conducted a phone interview with Physician #1. Physician #1 stated, he sees the residents' multiple times per week at the facility but does not always put his notes in the computer but will write handwritten notes in the physical chart. Physician #1 further stated, he needs to document more in the electronic chart, and agreed that most of his resident visits were not documented. On 4/23/24 at 12:10 PM, the surveyor team met with the LHNA, DO, RDCS and VPO. No further comments made regarding physician visit documentation. 39885 2. On 4/18/24 at 9:45 AM, the surveyor reviewed Resident #142's hybrid medical record which revealed that the resident's physician only documented one visit which was dated 4/11/24. There was not a documented physician's visit for Resident #142's admission and subsequent monthly visit for February 2024 and March 2024. On 4/18/24 at 9:47 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) of the second floor unit. The UM/LPN stated that Resident #142's physician visited residents a couple times a week but that she did not know how often the physician would write a note regarding the visit. She added that the physician would document the notes in the electronic medical record. On 4/18/24 at 12:44 PM, the surveyor interviewed the Director of Nursing (DON) regarding physician visits. The DON stated that the physician should write a note monthly. He added that Resident #142's physician did not have a partner or any other staff that would have written a note. On 4/18/24 at 01:16 PM, in the presence of the survey team, the surveyor told the Licensed Nursing Home Administrator, DON, Assistant DON and Regional Nurse the concern that Resident #142's physician did not have any documented visits prior to 4/11/24. On 4/19/24 at 12:00 PM, in the presence of the survey team, the Regional Nurse stated that there was no other documentation by Resident #142's physician and that there should have been. 39399 3. On 4/22/24 at 12:23 PM, the surveyor reviewed Resident #352's hybrid medical records. The resident was discharged from the facility on 1/31/24. The Admission Record (AR) documented that Resident #352 had diagnoses that included but were not limited, Acute Respiratory Failure, Pneumonia, Type II Diabetes Mellitus and Bipolar Disorder. A review of the physician progress notes (PN), revealed there were no notes written by Physician #1 from November 2023 to January 2024. 46049 4. On 4/16/24 at 12:00 PM, the surveyor reviewed Resident #138's hybrid medical records. The Admission Record (AR) documented that Resident #138 had diagnoses that included but were not limited, schizoaffective disorder, depression, and hyperlipidemia. A review of the physician progress notes (PN), revealed there were no notes written by Physician #1 from November 2023 to March 2024. 5. On 4/16/24 at 12:00 PM, the surveyor reviewed Resident #63's hybrid medical records. The Admission Record (AR) documented that Resident #138 had diagnoses that included but were not limited, cerebral infarction (stroke) with hemiplegia (paralysis on one side of the body) and hemiparesis (weakness affecting one side of the body), hypertension, and type 2 diabetes. A review of the PN, revealed there were no notes written by Physician #1 from November 2023 to March 2024. On 4/17/24 at 11:34 AM, the surveyor interviewed LPN/UM #2 about PN. LPN/UM #2 stated Physician #1 did not work with a nurse practitioner and documented in the electronic medical record (EMR). On 4/18/24 at 10:53 AM, the surveyor interviewed the ADON who stated Physician #1 documented in the EMR. The ADON reviewed the EMR of Resident #138 and Resident #63. The ADON could not find PNs by Physician #1 who was the residents' primary physician. The ADON stated she would follow up to provide further information. On 4/18/24 at 1:40 PM, the survey team met with the LNHA, DON and regional staff. The surveyor informed them of the concern of Resident #138 and Resident #63 not having any PN by their primary physician. On 4/19/24 at 9:13 AM, the surveyor interviewed the Medical Director who stated it was expected for physician visits at least monthly and every two months when alternating visits with a nurse practitioner or physician assistant. The Medical Director acknowledged it would be expected for physicians to document upon visiting residents. On 4/19/24 at 11:53 AM, the survey team met with the LNHA, DON and Director of Clinical Services (DCS). The DCS stated Physician #1 was in-serviced about documentation. The facility provided a PN that Physician #1 completed yesterday for April 2024. There was no additional information provided by the facility. On 4/23/24 at 10:32 AM, the survey team interviewed Physician #1 over the phone who stated physicians were required to visit residents at least once a month and he visited his residents in the facility 3-4 times a week. Physician #1 stated when visiting, he wrote PN, but would handwrite notes sometimes when computers were not available. Physician #1 further explained he would put it in the resident's paper chart and that it should be there. The surveyor informed Physician #1 there were no notes found in the paper chart of the residents identified and the facility did not provide any additional documentation. Physician #1 could not speak to why there were no PN for the residents identified. Physician #1 stated he understood the importance of completing PNs as it shows he is reviewing the residents' plan of care and visiting the residents. NJAC 8:39-23.2(b)(d)

Based on observation, interview, and record review it was determined that the facility failed to properly store and accurately label medications found during the initial unit inspection. This deficient practice was observed for 1 of 3 facility units examined, as evidenced by the following: On 4/15/24 at 12:50 PM, the surveyor inspected the 2nd floor low medication cart. Within the low medication cart the surveyor observed an opened 10ml bottle of Acetylcysteine 20% that was not labeled. Further examination of the bottle of Acetylcysteine revealed that the bottle did not have any documentation of a date or time the bottle was opened. Inspection of the bottle of Acetylcysteine 20% indicated on the label, Store in refrigerator after opening. and Discard opened vial after 96 hours. The surveyor interviewed the 2nd floor UM/LPN#1 who stated that it might belong to Resident #146 who does have an order for Acetylcysteine. The UM/LPN#1 confirmed that the medication should not have been stored without a label, date/time opened. Review of the facility Admission Sheet for Resident #146 revealed that the resident was admitted to the facility with diagnoses which included but were not limited to Acute Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease. A review of Resident #146's Comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/26/24, reflected that Resident #86 had a BIMS score of 15 out of 15, indicating an intact cognition. The surveyor reviewed the April 2024 electronic medication administration record (eMAR) which documented a Physician's order (PO) dated 3/20/24 for Acetylcysteine Solution 20% 10 ml inhale via nebulizer every 6 hours for mucous secretions. On 4/15/24 at 1:30 PM, the surveyor discussed the unlabeled, undated/untimed Acetylcysteine with the Director of Nursing (DON) who could not explain why the medication was stored this way. No further information was provided. NJAC 8:39- 29.4(b)2

Based on observation, interview, and record review, it was determined that the facility failed to provide the mandatory annual dental care services. This deficient practice was observed for 1 of 31 residents reviewed for dental care services, Resident #56, as evidenced by the following: On 04/15/24 12:27 PM, the surveyor observed the resident in bed, awake and alert. A review of the Admission Record for Resident #56 reflected that the resident was admitted to the facility with diagnoses that included but not limited to Depression, Post Traumatic Stress Disorder, Anorexia, Hypertension and Fracture of the left femur. A review of Resident #56's Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 1/11/24, reflected that the Brief Interview for Mental Status score of 15 of 15 indicating that the resident had intact cognition. The resident was admitted in the facility on 2/9/2023 and was recipient of Medicaid effective 3/19/23 and should have had at least an annual examination and treatment by a Dentist. The surveyor could not find any documentation that revealed visits from a Dentist nor any refusal of dental visits. On 4/19/24 at 2:38 PM, the surveyor discussed the above concern to the facility's the Licensed Nursing Home Administrator (LNHA), the [NAME] President of Operations (VPO), the Director of Clinical Services (DCS), the Regional Registered Nurse (RRN), the Director of Nursing (DON), Assistant DON. On 4/23/24 at10:45 AM, the facility's RRN confirmed to the surveyor that Resident #56 was not seen and evaluated by a Dentist since the resident was admitted to the facility. There was no further information provided. NJAC 8:39-15.1(a)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 4/15/24 at 09:21 AM, the surveyor in the presence of the entered the Food Service Director (FSD) observed the following during the kitchen tour: 1. During the kitchen inspection, the surveyor observed inside walk-in freezer, multiple boxed items stacked above 18 inches from ceiling. FSD stated he will do rearrange the boxes, so they are stored below the 18 inches from the ceiling. 2. On 4/16/24 at 10:38 AM, during the lunch meal preparation, the surveyor observed the Dietary Chef (DC), check the temperature of ground pork with a non-disinfected thermometer. The FSD had given the thermometer to the DC, who opened the thermometer probe and inserted the thermometer into the ground pork without disinfecting. The surveyor asked the chef why they did not disinfect the thermometer prior to checking the temperature of the ground pork, the chef stated, I thought the FSD disinfected the thermometer. The FSD stated, this was my fault, I should have told the chef to disinfect the thermometer prior to checking the food temperatures. We will discard the ground pork, because we contaminated the product. On 4/18/24 at 12:52 PM, the Regional Director of Clinical Services (RDCS) provided the surveyor with multiple facility policies including Food Receivable and Storage Policy and Kitchen Cleaning Policy both with a revised date of February 2024. The Food Receivable and Storage Policy states under the procedure section, 5. Store all items at least 6 off the floor, 18 from ceiling and aways from refrigerator, freezer, and dry storage area walls. The Kitchen Cleaning Policy states under the procedure section, All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. On 4/19/24 at 11:52 AM, the surveyor team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), RDCS and [NAME] President of Operations (VPO) with discuss concerns. The DON agreed that the DC had made a mistake by not disinfecting the food thermometer prior to checking the food temperatures and all stored items in the freezer must below stored below 18 inches from the ceiling. The DON further stated that the FSD has conducted an in-service with his staff for both kitchen concerns. No further comments made. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices to mitigate the spread of infection for 2 of 3 Nurses observed during medication administration, and [NAME] statement observed during wound treatment. The deficient practice was observed on 2 (3rd and 4th floor) out of 3 nurses observed during medpass or facility floors during medication administration observation. This deficient practice was evidenced by the following: 1. On 4/18/24 at 8:39 AM, the surveyor observed medication administration (med pass) performed on the 3rd floor, performed by a Licensed Practical Nurse (LPN) #3. The State Surveyor observed LPN#3 put his soapy hands immediately under the running water without scrubbing away from the water first. LPN#3 could not explain why he did not scrub his soapy hands away from the running water prior to rinsing the soap off. 2. On 4/18/23 at 8:52 AM, the surveyor observed med pass performed on the 4th floor, performed by LPN#4. The State Surveyor observed LPN#4 scrub her soapy hands for 5 seconds away from the water before rinsing them clean. LPN#4 could not explain why she did not scrub her soapy hands away from the running water for 20 seconds prior to rinsing the soap off. Review of Handwashing/Hand Hygiene Policy documented, The facility considers hand hygiene the primary means to prevent the spread of infections. Documented under Procedure, under Washing Hands 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds. 2. Rinse hands thoroughly under running water. On 4/18/23 at 11:52 AM, the surveyor met with the Director of Nursing, and the Assistant DON to discuss medpass. Medpass evaluations of LPN#2, 3/27/24 and LPN#3 2/6/24 were provided that showed requirements met during the evaluation. No further information was provided to explain the deficient practice during observation of hand washing. NJAC 8:39 - 19.4(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to 1) follow acceptable standards of practice for the administration of a controlled medication and 2) failed to maintain accurate accountability and documentation of a controlled medication for 1 of 23 Residents reviewed, Resident # 76, 3) clarifying a physician's medication order for 1 of 9 residents reviewed for medication administration Resident #37; 4) sign for the administration of medication that was not administered for 1 of 9 residents reviewed for medication administration Resident #37, 5) sign for behavior monitoring that was not completed for 3 of 9 residents (Resident #89, #84,and #39) reviewed for behavior logs, 6) use a facility approved blood pressure cuff for 1 of 2 nurses observed for medication administration pass; and 7) use the required method for disposing of unused or refused medications for 1 of 2 nurses observed for medication administration pass. These deficient practices were evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was evidenced by the following: 1) The Surveyor #2 reviewed the medical record for Resident #76. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/4/22 reflected that the resident had a brief interview for mental status (BIMS) score of 00 out of 15, which indicated severely impaired cognition. A review of the resident's individualized, comprehensive care plan reflected that Resident #76 had a [CONDITION(S)] with Interventions that included give [CONDITION(S)] medication as ordered by doctor. Monitor/document side effects and effectiveness. A review of the electronic Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Manufacturer's recommendations for [MEDICATION(S)] reflected that [MEDICATION(S)] should not be crushed. On 2/22/22 at 12:17 PM, Surveyor #2 interviewed the Licensed Practical Nurse (LPN)#2 who regularly administered medications to Resident #76. LPN #2 told the surveyor that she crushed Resident #76's medications including the [MEDICATION(S)] and administered all the medications through the G-tube. The surveyor asked LPN #2 if she was aware that [MEDICATION(S)] should not be crushed. LPN #2 replied, no I wasn't aware, I will call the doctor now. Review of the Certified Consultant Pharmacist Monthly Progress Notes dated 1/22/22 did not document any recommendations related to the [MEDICATION(S)] tablets being crushed. On 2/22/22/at 3:28 PM, Surveyor #2 conducted a phone interview with Resident #76's Primary Care Physician (PCP) who stated that he was not familiar with the medication [MEDICATION(S)] and wasn't aware it could not be crushed. He further stated that the pharmacy provider and consultant should have caught this and should have brought it to my attention. He told the surveyor that the hospital physician had originally ordered it and he just renewed it. The PCP acknowledged that he should have reviewed the medications prior to renewing them. On 2/22/22 at 3:43 PM, Surveyor #2 conducted a phone interview with the Consultant Pharmacist (CP) who stated she was unaware that [MEDICATION(S)] could not be crushed because she used the American Society of Consultant Pharmacy Medications not to be crushed list and [MEDICATION(S)] was not on it. She further stated that the Pharmacy Provider should have identified this and should have notified the facility and the Physician. 2.) On 02/23/22 at 9:02 AM, Surveyor #2 observed the LPN exit Resident #76's room and stated she had just administered the liquid [MEDICATION(S)] to Resident #76. The surveyor observed that the LPN had not signed the Individual Patient Controlled Substance Administration Record (IPCSAR) for the dose the LPN had already administered. The LPN stated, I Can't sign before I give it. The LPN further stated that it was her routine practice to sign the IPCSAR and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/23/22 at 9:07 AM, Surveyor #2 interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that she signed the IPCSAR and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/23/22 at 9:12 AM, the Nursing Supervisor stated that the IPCSAR should be signed when the medication is removed from the locked box and that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/23/22 at 9:47 AM, Surveyor #2 discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and the DON who stated that the IPCSAR should definitely be signed when the medication is removed from the locked box and prior to the administration of the medication. The DON stated she would be providing education to the nurses. A review of the Controlled Medication Administration Policy Revised April 2007 indicated: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. No other information was provided by the facility. 3) On 2/14/22 at 9:01 AM, Surveyor #5 observed the Registered Nurse (RN) on the 4th floor administering medications to residents including Resident #37. RN #3 opened a box with a pen injector of [MEDICATION(S)] (a medication used to control high blood sugar) medication. RN #3 reviewed the order, was unsure of how to use the delivery system pen injector and asked the Unit Manager (UM) for help. RN #3 administered the [MEDICATION(S)]. The box which contained the medication revealed that the medication was a once weekly dose. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #37's Admission Record revealed he/she was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #37's medical record progress notes revealed a telephone order from a physician to the facility on [DATE] for [MEDICATION(S)] 0.25 milligram (mg) or 0.5 MG/DOSE, Solution Pen-injector 2 milligram (MG)/1.5 milliliter (ML) Inject 0.5 mg subcutaneously one time a day for DM for 1 Week. On 2/14/2022 at 11:49 AM, the Nursing Supervisor (NS) who took the verbal order stated the process was to call the physician, enter the order into the computer and document in the progress note. The NS stated that the pharmacy would obtain the order directly from the electronic medical record where the order was entered. The NS stated that if the order was questionable, the pharmacy would call. She went on to state that the pharmacy did not call regarding the [MEDICATION(S)], that [MEDICATION(S)] was a new medication, she was not familiar with and was not sure if any monitoring needed to be done. She indicated that she plotted the order on the MAR for 7 days. The NS stated that she was not too sure if other nurses were familiar with the [MEDICATION(S)] and that there was a drug book that the nurses can consult for protocol for new medication. During an interview on 2/14/22 at 12:17 PM, the DON stated to two surveyors that the consultant pharmacist sent her a recommendation via email on 2/13/22 regarding the [MEDICATION(S)] being weekly. The DON stated she phoned but was unable to reach the ordering physician on 2/13/22. The DON stated she next called the pharmacy who delivers the medications to the facility this morning 2/14/22. The DON further stated that if a nurse was not familiar with a medication, the expectation would be to look it up (the medication) and that the RN supervisor who was unfamiliar with the [MEDICATION(S)], should have looked up the [MEDICATION(S)]. The DON stated that a medication being given for the first time in the facility, should be accompanied by education to the nurses. During an interview on 2/14/2022 at 1:40 PM, the DON acknowledged that she had not tried to reach the medical director to clarify the order until the following day when the surveyors brought it to her attention. An interview with RN #1 revealed that she should have prime the pen to ensure that the correct dose was delivered. She further stated that she should have read the instructions inside the box prior to administer the [MEDICATION(S)]. Later on during medication reconciliation it was noted that [MEDICATION(S)] was ordered and transcribed incorrectly. The pharmacy consultant indicated on the medication review form that [MEDICATION(S)] should be administered weekly not daily. The form was faxed to the Director of Nursing on 02/13/2022 for follow up. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the provider pharmacy on 02/16/2022 at 10:28 AM, revealed that one [MEDICATION(S)] pen was delivered at the facility on 02/12/2022. The facility indicated that [MEDICATION(S)] was a new medication and no other resident was ordered [MEDICATION(S)] at the facility. On 02/16/2022 at 12:20 PM an interview with RN #2 who initialed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she signed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the electronic progress notes from 02/14/2022 to 02/23/2022 and could not find any late entry in the clinical record regarding the [MEDICATION(S)] order. An interview with Registered Nurse #3 on 02/16/2022 at 12:40 PM, who signed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #3 stated that she was aware that the medication was available but failed to administer the [MEDICATION(S)] dose because the medication was to be administered weekly. There was no documented evidence that RN #3 clarified the order with the provider pharmacy or called the physician to clarify the order. She did not discussed the order with the Nursing Supervisor on duty that day nor left a note for the DON to follow up. On 02/17/2022 at 12:50 PM, the DON was asked to comment on the [MEDICATION(S)] order. The DON indicated that she was aware that the [MEDICATION(S)] medication had not been administered on 02/12/22 and 02/13/22 as reflected on the MAR. She further stated that the physician was notified, the nurses were in-serviced and disciplinary action will follow. On 02/22/2022 at 10:01 AM, the survey team met with the administrator, the DON, ADON and the Regional Nurse and discussed again the above observations and concerns. The surveyor requested the facility's policy and procedure for following physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 02/23/2022 the DON provided a form titled, Administering Medications last revised April 2019, which indicated the following: Policy heading Medications are administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation. Only persons licensed or permitted by this state to prepare, administer and document the administration medications may do so. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. Medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes, and or the need for additional staff training. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician, or the Medical Director to discuss the concerns. The individual administering the medication checks the label three (3 ) times to verify the right resident, right medication, right dosage, right time and right method (route ) of administration before giving the medication. Each nurses' station has a current Physician's Desk Reference (PDR) and/other medication reference, as well as a copy of the surveyor guidance for 755-761 (Pharmacy Services ) available. Manufacturer's instructions or user's manuals related to any medication administration devices are kept with the devices or at the nurses' station. The policy was not being followed. The facility did not contact the Medical Director for guidance until the above concern was brought to the DON's attention on 02/15/2022. 4) On 2/15/22 at 9:44 AM, the DON stated that the Medical Director discontinued the [MEDICATION(S)], ordered blood sugars and monitoring. On 2/16/22 at 9:29 AM, the ordering physician of the [MEDICATION(S)] for Resident #37 stated the maximum dose of [MEDICATION(S)] would be 1 mg a week and the resident had received three doses of 0.25 mg. On 2/16/22 at 12:26 PM, Surveyor #5 phoned RN #3 who stated that she signed but did not administer the [MEDICATION(S)]. RN #3 stated that she signed in error because she had 30 residents and just did not document that she did not administer the [MEDICATION(S)]. On 2/22/22 at 9:14 AM, the DON stated that she had spoken to RN #3 and LPN #4 about administering the [MEDICATION(S)]. The DON stated that both nurses informed her they never administered the medication, had signed that they did, and never documented differently. On 2/16/22 at 12:45 PM, Surveyor #2 reviewed the Behavior Monitoring Form (BMF) for Resident #44 for January 2022 which included the following: The Behavior for the psychoactive medication for [MEDICATION(S)] 250 mg daily at bedtime had indicated that the behavioral symptoms of disruptive behaviors were to have been monitored and documented daily on all three shifts. A review of the BMF reflected that the symptom of disruptive behavior was only documented for the 7 AM to 3 PM shift and on the 3 PM to 11 PM shift each day for the month of January. The 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. On 2/17/22 at 11:09 AM, Surveyor #2 reviewed Resident #44's BMF for January 2022 again and the surveyor observed that additional information had been added to the forms which included the following: The BMF for [MEDICATION(S)] 250 mg had the behavioral symptom of disruptive behaviors documented for the 11 PM to 7 AM shift for each day of the month of January. On 2/17/22 at 11:10 AM, the 4th floor RN/UM stated that the LPN worked last night and that his signature was not there yesterday. On 2/17/22 at 12:53 PM, the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) met with the survey team. The DON stated that it should not be happening that one staff member signs behavior monitoring every day whether or not they are present on the unit. The DON stated that documentation goes, forward and that staff should not go backwards to change documentation logs. On 2/18/22 at 9:05 AM, the DON presented the survey team a statement from the LPN who changed the BMFs. The statement indicated that the LPN signed and backdated the January 2022 Behavioral Monitoring Sheets and stated that it was an unwritten common practice to sign the logs for the dates where the nurses cannot [be] reached to sign the log as need demands. On 2/22/22 at 8:30 AM, the DON presented the survey team a statement from the Registered Nurse Supervisor which indicated that, Nurses are reminded to complete and initial the behavior monitoring forms every shift during 11-7 shift. The facility policy, Behavioral Assessment, Intervention and Monitoring, revised March 2019 indicated that staff will evaluate the resident's mood and behavior, will identify, and document the onset, duration, intensity ad frequency of behavioral symptoms, and when medications are prescribed for behavioral symptoms, documentation will include monitoring for efficacy and adverse consequences. The facility policy, Charting and Documentation, revised July 2017 indicated that documentation in the medical record will be objective, complete, and accurate. 5) On 2/16/22 at 10:40 AM, Surveyor #3 reviewed Resident #39's Behavior Monitoring Forms for January 2022 which included the following: One form for the psychoactive medication [MEDICATION(S)] 5 mg had indicated that the behavioral symptoms of hitting and pacing were to have been monitored and documented daily on all three shifts. A review of the form reflected that the symptom of hitting was only documented for the 7 AM to 3 PM shift each day of the month of January. The 3 PM to 11 PM shift and 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. The symptom of pacing was only documented for the 7 AM to 3 PM and 3 PM to 11 PM shift each day of the month of January. The 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. One form for the psychoactive medication [MEDICATION(S)] 2 mg had indicated that the behavioral symptom of hitting was to have been monitored daily on all three shifts. A review of the form reflected that the symptom of hitting was only documented for the 7 AM to 3 PM shift and 3 PM and 11 PM shift each day of the month of January. 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. On 2/17/22 at 11:40 AM, Surveyor #3 reviewed Resident #39's Behavior Monitoring Forms for January 2022 again and additional information was added to the forms which included the following: One form for psychoactive medication [MEDICATION(S)] 5 mg had the symptoms of hitting and pacing documented for the 11 PM to 7 AM shift for each day of the month of January. One form for psychoactive medication [MEDICATION(S)] 2 mg had the symptom of hitting documented for the 11 PM to 7 AM shift for each day of the month of January. At 12:22 PM, Surveyor #3 interviewed the fourth floor Unit Manager (UM). The UM confirmed that the 11 PM to 7 AM shift documentation on both of Resident #39's Behavior Monitoring Forms was not on the forms the day before. She added that a staff member must have signed it during the night. The UM also confirmed that the initial listed each day on the 11 PM to 7 AM shift appeared to be the same initial. She then added that only the staff member that is working on that date should sign the form for that date. 6) On 2/14/22 at 8:27 AM, Surveyor #1 observed LPN #1 during the LPN's medication administration pass. LPN #1 was observed to have used her personal blood pressure cuff with a Velcro wrist band, directly on the right wrist of an unsampled resident #1. Surveyor #1 observed that the facility provided portable vitals machine, which included a blood pressure monitor, was in the hall across from LPN #1's medication cart. 7) On 2/14/22 at 8:18 AM, Surveyor #1 was observing LPN #1 during medication administration. LPN #1 had attempted to administer medications to two unsampled residents. The unsampled resident #2 had refused one both medications that were to be administered. LPN #1 returned to the medication cart with the refused medications in a paper pill cup and threw them both into the sharp's container located on the side of the medication cart. At 8:39 AM, the unsampled resident #3 had refused one of four medications to be administered. LPN #1 returned to the medication cart with the refused medication in a paper pill cup and threw it into the sharp's container located on the side of the medication cart. On 2/14/22 at 9:24 AM, LPN #1 stated the facility provided a medication destroyer but it wasn't around so she just threw the refused medications in the sharp's container. LPN #1 stated her personal wrist blood pressure cuff she was using had been approved by the DON for her to use on residents. On 2/14/22 at 9:43 AM, the DON stated if a resident refused medications, those pills are to be discarded in the drug buster. The DON stated the medications should not be thrown into the sharp's container because the facility would want to be sure nobody can get to them. On 2/14/22 at 10:10 AM, the DON stated that the staff were not to use their own personal blood pressure cuffs because a wrist blood pressure cuff was different than an arm blood pressure cuff and there would be no way to document the wrist blood pressure. Also, that there was no way to assure the accuracy of the staff's personal equipment. A review of the facility provided, Medication Pass Observation, dated 12/1/21 for LPN #1, included but was not limited to PRN, refused and/or partial doses are properly documented and disposed of. The Medication Pass Observation that LPN #1 had been deemed competent / had passed the medication pass observation competency. A review of the facility provided Inservice with the topic of Medication Pass, dated 1/14/22, included if any medication needs to be wasted must use the drug buster, and was signed by LPN #1. A review of the facility provided, Blood Pressure, Measuring policy and procedure, updated 10/19, included but was not limited to a stop in the procedure to wrap the blood pressure cuff evenly around the upper arm, approximately one inch from the elbow. On 2/16/22 at 10:20 AM, Surveyor #4 reviewed the Behavior Monitoring Forms for Resident #89 for January 2022 which included the following: The Behavior Monitoring Form for the psychoactive medication [MEDICATION(S)] 3 mg twice a day (BID) had indicated that the behavioral symptoms of delusions were to have been monitored and documented daily on all three shifts. A review of the Behavioral Monitoring Form reflected that the symptom of delusions was only documented for the 7 AM to 3 PM shift and on the 3 PM to 11 PM shift each day for the month of January. The 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. On 2/17/22 at 11:45 AM, Surveyor #4 reviewed Resident #89's Behavior Monitoring Form for January 2022 again and additional information was added to the forms which included the following: The Behavior Monitoring Form for [MEDICATION(S)] 3 mg BID had the behavioral symptom of delusions documented for the 11 PM to 7 AM shift for each day of the month of January. On 2/16/22 at 11:14 AM, Surveyor #4 reviewed Resident #84's Behavior Monitoring Forms for Resident #84 for January 2022 which included the following: The Behavior Monitoring Form for the psychoactive medication [MEDICATION(S)] had indicated that the behavioral symptoms of sexually preoccupied were to have been monitored and documented daily on all three shifts. A review of the Behavioral Monitoring Form reflected that the symptom of sexually preoccupied was only documented for the 7 AM to 3 PM shift and on the 3 PM to 11 PM shift each day for the month of January. The 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. On 2/17/22 at 11:46 AM, Surveyor #4 reviewed Resident #84's Behavior Monitoring Form for January 2022 again and additional information was added to the forms which included the following: The Behavior Monitoring Form for [MEDICATION(S)] had the behavioral symptom of sexually preoccupied documented for the 11 PM to 7 AM shift for each day of the month of January. On 2/17/22 at 12:53 PM, the DON and LNHA met with the survey team. The DON stated that it should not be happening that one staff member signs behavior monitoring every day whether or not they are present on the unit. The DON stated that documentation goes, forward and that staff should not go backwards to change documentation logs. On 2/18/22 at 9:05 AM, the DON presented the survey team a statement from the LPN who changed the Behavior Monitoring Forms. The statement indicated that the LPN signed and backdated the January 2022 Behavioral Monitoring Sheets and stated that it was an unwritten common practice to sign the logs for the dates where the nurses can not [be] reached to sign the log as need demands. On 2/22/22 at 8:30 AM, the DON presented the survey team a statement from the Registered Nurse Supervisor which indicated that, Nurses are reminded to complete and initial the behavior monitoring forms every shift during 11-7 shift. The facility policy, Behavioral Assessment, Intervention and Monitoring, revised March 2019 indicated that staff will evaluate the resident's mood and behavior, will identify and document the onset, duration, intensity and frequency of behavioral symptoms, and when medications are prescribed for behavioral symptoms, documentation will include monitoring for efficacy and adverse consequences. A review of the facility provided, Charting and Documentation policy and procedure, revised 7/17, included but was not limited to policy statement: all services provided to the resident, progress toward the care plan goals, or changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Interpretation and implementation: 2. the following information is to be documented in the resident medical record: a. objective observations; b. medications administered; c. treatments or services performed; d. changes in the resident's condition; 3. events, incidents or accidents involving the resident; and f. progress toward or changes in the care plan goals and objectives. NJAC 8:39-11.2 (b), 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to consistently and adequately document and monitor specific target behaviors and that Behavior Monitoring Forms (BMF) were completed for antipsychotic and antidepressant medications after the administration of [CONDITION(S)] medications. This deficient practice was identified for 9 of 9 residents reviewed for unnecessary medications Resident #23, #44, #39, #363, #63, #55, #79, # 89 and #84 was evidenced by the following: 1. On 2/18/22 at 12:40 PM, surveyor #1 observed Resident #44 ambulating in the dining room. The surveyor attempted to speak to the resident, but the resident did not respond to the surveyor. The Registered Nurse on the 4th floor (RN) stated that Resident #44 was alert, confused, ambulated with assistance and had no behaviors. Surveyor #1 reviewed the medical record for Resident #44. A review of the Admission record reflected that the resident was admitted to the facility with diagnoses which included Dementia with behavioral disturbance and [CONDITION(S)]. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/14/22 reflected that Resident #44 had a brief interview for mental status (BIMS) score of 2 out of 15, which indicated severely impaired cognition. A further review of the MDS, indicated that the resident exhibited behaviors of wandering which occurred daily and received [CONDITION(S)] medications on 7 out of the last 7 days during the look back period. A review of the resident's individualized, comprehensive care plan revised 1/12/22 included a care concern for Resident #44 that had behaviors which included ambulating up and down the hallway, agitation, wandering in and out of other residents rooms and lying on his/her roommates bed. Interventions included to redirect resident; intervene as necessary to protect the rights and safety of other residents; approach in a calm manner; assess personal needs; and to monitor and document behaviors. A review of the Physician Order Summary (POS) indicated an order dated 2/13/22 for [MEDICATION(S)] (a medication used to treat [CONDITION(S)]), 25 mg tablet by mouth with [MEDICATION(S)] 25 mg ½ tablet for a total of 37.5 mg to be administered at bedtime for [CONDITION(S)]. A further review of the Current POS reflected an order for [MEDICATION(S)] (an antidepressant medication) 50 mg one tablet by mouth to be administered at bedtime for depression. On 2/16/22 at 10:30 AM, the surveyor reviewed the BMF(s) for Resident #44. The review indicated that the behavior monitors for the [MEDICATION(S)] were incomplete for November 2021 with behavior monitoring occurring on 3 out of 30 days on the 7 AM- 3 PM shifts 11/1, 11/4, 11/5; 1 out of 30 days (11/1) on the 3 PM- 11 PM shifts and on the 11 PM-7AM shifts monitoring was done from 11/1-11/24 but the remainder of the days and shifts were blank. The review failed to indicate any BMF(s) for December 2021. The review indicated an incomplete BMF(s) for January 2022 with no monitoring occurring on any 11 PM to 7 AM shifts. The review failed to indicate any BMF(s) for February 2022. Further review of the BMF(s) reflected that no monitoring was done for the use of the antidepressant medication. The BMF(s) for November 2021 listed Resident #44 behavioral symptom as disruptive and pacing. The BMF(s) for January 2022 listed Resident #44's behavioral symptom as disruptive. The [CONDITION(S)] Note Monthly effective on 11/22/21 and inclusive of Resident #44's behaviors for the month of November 2021 listed the resident's targeted behaviors as pacing affecting others and antipsychotic/anxiety. The [CONDITION(S)] Note Monthly indicated that the resident had 1 episodes of pacing affecting others and 1 episode of antipsychotic/antianxiety. The BMF for November 2021 indicated that Resident #44 was being monitored for disruptive and pacing affecting others and failed to indicate that the resident was being monitored for either anxiety or [CONDITION(S)]. The [CONDITION(S)] Note Monthly effective on 1/13/22 and inclusive of Resident #44's behaviors for the month of December 2021 listed the resident's targeted behaviors as pacing affecting others and antipsychotic/antianxiety. The [CONDITION(S)] Note Monthly indicated that the resident had 30 episodes of pacing affecting others and 30 episodes of [CONDITION(S)]/anxiety. There was no evidence of a BMF for December 2021. The [CONDITION(S)] Note Monthly effective on 2/13/22 and inclusive of Resident #44's behaviors for the month of January 2022 listed the resident's targeted behaviors as pacing affecting others and antipsychotic/antianxiety. The [CONDITION(S)] Note Monthly indicated that the resident had 30 episodes of each behavior. The BMF for January 2021 indicated that Resident #44 was being monitored for disruptive behavior and failed to indicate that the resident was being monitored for [CONDITION(S)] and anxiety. 2. On 2/18/2022 at 12:50 PM, surveyor #1 observed Resident #23 in their room lying in bed. Resident #23 sat up and greeted the surveyor with a smile and incoherent speech. The surveyor reviewed the medical record for Resident #23. A review of the Admission Record reflected that the resident was admitted to the facility with diagnoses which included Dementia, Depression and [CONDITION(S)] (loss of ability to understand or express speech). A review of the Annual MDS, dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 8 out of 15, which indicated moderately impaired cognition. A further review of the MDS, indicated that the resident exhibited no behavioral symptoms and received antidepressant medications on 7 out of the last 7 days during the look back period. A review of the resident's individualized, comprehensive care plan dated 12/26/19 included a care concern that the resident had a behavior problem related to depression and agitation and indicated that the resident was taking antidepressant and antipsychotic medications. A review of the POS indicated an order dated 4/16/21 for [MEDICATION(S)] (a medication used to treat depression) tablet 25 mg given once a day which was active and an active order for [MEDICATION(S)] ER ( a medication used to treat mood disorders) 250 mg tablet at bedtime for mood behavior. On 2/18/2022 at 12:55 PM, the surveyor reviewed the BMF for Resident #23's mood stabilizer medication. The review failed to indicate behavior monitoring for November or December 2021 and for February 2022 the monitoring didn't start until the16th. The review indicated incomplete behavior monitoring for November, December 2021 and January, February 2022 with no monitoring for the use of the antidepressant medications. The [CONDITION(S)] Note Monthly effective on 12/8/21 and inclusive of Resident #23's behaviors for the month of November 2021 listed the resident's targeted behaviors as helplessness and loss of interest in activities. The [CONDITION(S)] Note Monthly failed to indicate the number of times that the resident exhibited each behavior. There was no evidence of a BMF for November 2021. The [CONDITION(S)] Note Monthly effective on 1/10/22 and inclusive of Resident #23's behaviors for the month of December 2021 listed the resident's targeted behaviors as helplessness and loss of interest in activities. The [CONDITION(S)] Note Monthly failed to indicate the number of times that the resident exhibited each behavior during the month of December. There was no evidence of a BMF for December 2021. The [CONDITION(S)] Note Monthly effective on 2/10/22 and inclusive of Resident #23's behaviors for the month of January 2022 listed the resident's targeted behaviors as pacing affecting others, excessive talking disrupting care and appetite disturbances,. The [CONDITION(S)] Note Monthly failed to indicate the number of times that the resident exhibited each behavior. The BMF(s) for January 2022 failed to indicate that the resident was being monitored for either appetite disturbances or helplessness. 5. On 2/17/22 at 10:34 AM, surveyor #3 observed Resident #55 in the unit day area, seated in a wheelchair with eyes closed. The surveyor reviewed the admission record that indicated Resident #55 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included but not limited to Dementia with behavioral disturbances and [CONDITION(S)]. The surveyor also reviewed the February 2022 electronic POS which reflected an order dated 7/6/21 for [MEDICATION(S)] 5 mg daily every 12 hours for Dementia with behavior and [MEDICATION(S)] Sprinkles Capsule Delayed Release 125 mg 1 capsule three times a day for Dementia with behavioral disturbance. A review of the Annual MDS, dated [DATE] reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 01, which indicated that the resident had severely impaired cognition. Surveyor #3 reviewed the monthly [CONDITION(S)] Notes (PN) for the month of January 2022 through February 2022. The resident's target behaviors identified by the facility for monitoring documentation included, pacing affecting others, cursing affecting others, helplessness, and loss of interest in activities. A review of the BMF for January 2022 revealed that the target behavior monitored was for difficult to care. Additional review of the February 2022 BMF revealed a target behavior monitored for pacing. The BMF forms did not match the specific target behaviors being monitored daily for Resident #55. On 2/22/22 at 12:30 PM, the surveyor discussed the above concern to the Administrator, Regional Nurse and Director of Nursing (DON). The DON stated that the target behaviors identified in the PN must match the target behaviors under the BMF form. No further information was provided. 6. On 2/17/22 at 10:19 AM, the surveyor observed Resident #63 in the room, awake and was seated on the bed. The resident did not look at the surveyor or speak when spoken to. The surveyor reviewed the admission record that indicated Resident #63 was admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's Disease, Depression and [CONDITION(S)]. The surveyor also reviewed the February 2022 electronic POS which reflected an order dated 1/30/21 for [MEDICATION(S)] tablet 7.5 mg 1 tablet at bedtime for Depression. A review of the Quarterly MDS, dated [DATE], indicated a BIMS score of 03, which indicated that the resident had severely impaired cognition. Further review of Resident #63's medical records revealed that there was no documentation found on the side effects of the anti depressant to the resident being monitored and documented. On 2/22/22 at 12:30 PM, the surveyor discussed the above concern with the Administrator, Regional Nurse and Director of Nursing (DON). No further information was provided. 8. On 2/11/22 at 9:46 AM, Surveyor #2 observed Resident #39 lying in bed with the sheet covering his/her head. Resident #39 then sat up in the bed but did not respond to Surveyor #2. The surveyor reviewed the medical record for Resident #39. A review of the Admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, dementia without behavioral disturbance, [CONDITION(S)] (an abnormal condition of the mind that results in difficulties determining what is real and what is not real) and hypertension (high blood pressure). A review of the quarterly MDS, dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 1 out of 15, which indicated severe impaired cognition. A further review of the MDS, indicated that the resident had no behaviors and received [CONDITION(S)] medications, an antipsychotic medication and an antianxiety medication, on 7 out of the last 7 days during the look back period. A review of the resident's individualized, comprehensive care plan dated included a care concern that the resident used [CONDITION(S)] medications (medication affecting the mind or mental processes) with diagnosis of MNC DIS (major neurocognitive disease) with behavioral disturbance. Interventions included, but were not limited to, monitor/record occurrence of for target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. A review of the POS of active orders as of 2/17/22, indicated the following [CONDITION(S)] medication orders: [MEDICATION(S)] tablet (medication used for the short-term treatment of agitation that occurs with certain mental/mood disorders) 2 mg give ½ tablet by mouth one time a day for behavioral disturbance; [MEDICATION(S)] tablet (medication used to treat anxiety) 5 mg give 1 tablet by mouth two times a day for anxiety; [MEDICATION(S)] tablet (medication used to treat certain psychiatric conditions) delayed release 125 mg give 1 tablet by mouth three times a day for agitation. A review of Resident #39's November 2021, December 2021, January 2022 and February 2022 electronic Medication Administration Record (eMAR) reflected that the resident received the three [CONDITION(S)] medications of [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)], each month. On 2/16/22 at 10:30 AM, in the presence of Surveyor #5, Surveyor #2 asked the Registered Nurse (RN) where the facility documented the behavior monitoring for residents that received [CONDITION(S)] medications. The RN provided Surveyor #2 a black binder labeled Behavior Monitoring which contained BMFs for the residents on the fourth floor that received [CONDITION(S)] medications. Surveyor #2 looked in the binder to obtain Resident #39's February 2022 Behavior Monitoring sheet. There was no BMF(s) for February 2022 for Resident #39. There was 3 BMF(s) for January 2022 for Resident #39. Surveyor #2, in the presence of Surveyor #5, asked the RN what the process was for behavior monitoring for residents on [CONDITION(S)] medications. The RN stated that they use the BMF(s) for any resident on [CONDITION(S)] medications to monitor target behaviors and for side effects of the medications. She added that the forms for the month were kept in the black binder and that a monthly summary was done in the computer. The RN confirmed that there was not a Behavior Monitoring Form for February 2022 for Resident #39. She added that there should be. Surveyor #2 then reviewed Resident #39's BMF(s) for January 2022 which included the following information: One form for the psychoactive (also known as [CONDITION(S)]) medication [MEDICATION(S)] 5 mg had indicated that the behavioral symptoms of hitting and pacing were to have been monitored and documented daily on all three shifts. A review of the form reflected that the symptom of hitting was only documented for the 7 AM to 3 PM shift each day of the month of January. The 3 PM to 11 PM shift and 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. The symptom of pacing was only documented for the 7 AM to 3 PM and 3 PM to 11 PM shift each day of the month of January. The 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. The form indicated that Resident #39 did not have any episodes of hitting or pacing for the month of January 2022. One form for the psychoactive medication [MEDICATION(S)] 2 mg had indicated that the behavioral symptom of hitting was to have been monitored daily on all three shifts. A review of the form reflected that the symptom of hitting was only documented for the 7 AM to 3 PM shift and 3 PM to 11 PM shift each day of the month of January. The 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. The form indicated that Resident #39 did not have any episodes of hitting for the month of January 2022. One form for the psychoactive medication [MEDICATION(S)] 125 mg had indicated that the behavioral symptom of hitting was to have been monitored daily on all three shifts. A review of the form reflected that the symptom of hitting was only documented for the 7 AM to 3 PM shift and 3 PM to 11 PM shift each day of the month of January. The 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. The form indicated that Resident #39 did not have any episodes of hitting for the month of January 2022. There was no evidence that the facility documented Resident #39's behavior monitoring daily on all three shifts for January 2022. At 10:57 AM, Surveyor #2 reviewed Resident #39's January 2022 Monthly [CONDITION(S)] Note dated 2/13/22, which included the following: 1st [CONDITION(S)] Medication-Busipirone ([MEDICATION(S)]) 5 mg; Target Behavior- Pacing affecting others; Monthly total-9. 2nd [CONDITION(S)] Medication- [MEDICATION(S)] 125 mg; Target Behavior- Pacing affecting others; Monthly total-left blank. 3rd [CONDITION(S)] Medication-[MEDICATION(S)] ([MEDICATION(S)]) 2 mg; Target Behavior- Pacing affecting others; Monthly total-9. Resident #39's Monthly [CONDITION(S)] Note and the Behavior Monitoring Forms for January 2022 did not contain the same information. The target behaviors that were to be monitored for each medication and the total amount of episodes that occurred during the month were different when the facility summarized the daily Behavior Monitoring Forms into the Monthly [CONDITION(S)] Note. On 2/16/22 at 11:32 AM, in the presence of Surveyor #5, Surveyor #2 interviewed the Assistant Director of Nursing (ADON) regarding the facility process for behavior monitoring for residents on [CONDITION(S)] medications. The ADON stated that the staff are to document daily on all three shifts on the Behavior Monitoring Form and if they need to describe the behavior additionally, they should write a note in the computer. She then added that the staff would use the daily Behavior Monitoring Forms to document the monthly [CONDITION(S)] Note Summary. Surveyor #2 then asked the ADON if the information should be the same on the Behavior Monitoring Form and the monthly [CONDITION(S)] Note Summary. The ADON stated that the information should be the same. At 11:35 AM, Surveyor #2 asked the fourth floor Unit Manager (UM) for Resident #39's November 2021 and December 2021 Behavior Monitoring Forms. At 11:38 AM, the UM provided Surveyor #2 an additional black binder which contained previous months of Behavioral Monitoring Forms. The binder contained forms from 2021 for the months of January, February, March, June, July and November. Surveyor #2 then asked the UM for Resident #39's December 2021. The UM stated that she would look in her office for the December 2021 forms. Surveyor #2 then reviewed Resident #39's Behavior Monitoring Forms for November 2021 which included the following information: One form for the psychoactive medication [MEDICATION(S)] 5 mg had indicated that the behavioral symptom of hitting and pacing was to have been monitored daily on all three shifts. A review of the form reflected that the symptoms of hitting and pacing was only documented for the 11 PM to 7 AM shift for November 1 through November 23. The remaining 11 PM to 7 AM shifts from November 24 through November 30 were blank (not documented). The 7 AM to 3 PM and 3 PM to 11 PM shift were blank (not documented) for each day of the month of November. The form indicated that Resident #39 did not have any episodes of hitting or pacing for the November 2021. One form for the psychoactive medication [MEDICATION(S)] 2 mg had indicated that the behavioral symptom of hitting and pacing was to have been monitored daily on all three shifts. A review of the form reflected that the symptoms of hitting was only documented for the 11 PM to 7 AM shift for November 1 through November 28. The remaining 11 PM to 7 AM shifts from November 29 through November 30 were blank (not documented). The symptom of pacing was only documented for the 11 PM to 7 AM shift for November 1 through November 23. The remaining 11 PM to 7 AM shifts from November 24 through November 30 were blank (not documented). The 7 AM to 3 PM and 3 PM to 11 PM shift were blank (not documented) for each day of the month of November. The form indicated that Resident #39 did not have any episodes of hitting or pacing for the November 2021. One form for the psychoactive medication [MEDICATION(S)] 125 mg had indicated that the behavioral symptom of hitting and pacing was to have been monitored daily on all three shifts. A review of the form reflected that the symptoms of hitting and pacing was only documented for the 11 PM to 7 AM shift for November 1 though November 23. The remaining 11 PM to 7 AM shifts from November 24 through November 30 were blank (not documented). The symptom of hitting was documented on the 3 PM to 11 PM on November 1. The remaining 3 PM to 11 PM shifts were blank (not documented). The 7 AM to 3 PM shifts were blank (not documented). The form indicated that Resident #39 did not have any episodes of hitting or pacing for the November 2021. There was no evidence that the facility documented Resident #39's behavior monitoring daily on all three shifts for January 2022. Surveyor #2 then reviewed Resident #39's November 2021 Monthly [CONDITION(S)] Note dated 12/10/21, which included the following: 1st [CONDITION(S)] Medication-Busipirone ([MEDICATION(S)]) 5 mg; Target Behavior- Pacing affecting others; Monthly total-left blank. 2nd [CONDITION(S)] Medication- [MEDICATION(S)] 125 mg; Target Behavior- Pacing affecting others; Monthly total-left blank. 3rd [CONDITION(S)] Medication-[MEDICATION(S)] ([MEDICATION(S)]) 2 mg; Target Behavior- Pacing affecting others; Monthly total-left blank. The Monthly [CONDITION(S)] Note and the Behavior Monitoring Forms for November 2021 did not contain the same information. The target behaviors that were to be monitored for each medication were different when the facility summarized the daily Behavior Monitoring Forms into the Monthly [CONDITION(S)] Note. On 2/17/22 at 12:22 PM, Surveyor #2 interviewed the UM. The UM stated that she did not find Resident #39's December 2021 BMF. Surveyor #2 then reviewed Resident #39's December 2021 Monthly [CONDITION(S)] Note dated 1/10/22, which included the following: 1st [CONDITION(S)] Medication-Busipirone ([MEDICATION(S)]) 5 mg; Target Behavior- Pacing affecting others; Monthly total-9. 2nd [CONDITION(S)] Medication- [MEDICATION(S)] 125 mg; Target Behavior- Pacing affecting others; Monthly total-left blank. 3rd [CONDITION(S)] Medication-[MEDICATION(S)] ([MEDICATION(S)]) 2 mg; Target Behavior- Pacing affecting others; Monthly total-9. 9. On 2/11/22 at 9:41 AM, Surveyor #2 observed Resident #363 lying in bed and was repeating a phrase in Spanish. Resident #363 did not respond to the surveyor. The surveyor reviewed the medical record for Resident #363. A review of the Admission record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, Alzheimer's disease, hypertension (high blood pressure) and persistent mood disorder. A review of the admission MDS, dated [DATE], reflected that the resident had a BIMS score of 6 out of 15, which indicated severe impaired cognition. A further review of the MDS, indicated that the resident had verbal behavioral symptoms directed toward others daily and other behavioral symptoms not directed toward others daily. The MDS also indicated that the resident received [CONDITION(S)] medication, an antidepressant, on 7 out of the last 7 days during the look back period. A review of the resident's individualized, comprehensive care plan included a care concern for the resident that had depression, mood disorder and anxiety and included yelling/screaming at times. Interventions included but were not limited to; allow resident to vent feelings; if resident exhibits any abnormal behavior, allow to calm down and then reapproach; medication reductions as needed. A review of the POS of active orders indicated the following [CONDITION(S)] medication orders: [MEDICATION(S)] Tablet Delayed release 250 mg give 1 tablet by mouth two times a day for mood disorder; [MEDICATION(S)] tablet (medication used to treat depression and anxiety) 5 mg give 1 tablet by mouth one time a day for depression/general anxiety. A review of Resident #363's January 2022 and February 2022 electronic Medication Administration Record (eMAR) reflected that the resident received the two [CONDITION(S)] medications of [MEDICATION(S)] and [MEDICATION(S)] each month. On 2/16/22 at 10:30 AM, in the presence of Surveyor #5, Surveyor #2 asked the Registered Nurse (RN) where the facility documented the behavior monitoring for residents that received [CONDITION(S)] medications. The RN provided Surveyor #2 a black binder labeled Behavior Monitoring which contained BMF(s) for the residents on the fourth floor that received [CONDITION(S)] medications. Surveyor #2 looked in the binder to obtain Resident #363's February 2022 Behavior Monitoring Form. There was no BMF for February 2022 for Resident #363. There was no evidence that the facility documented Resident #363's behavior monitoring daily on all three shifts for February 2022. Surveyor #2 then looked in the binder to obtain Resident #363's January 2022 B. There was no BMF for January 2022 for Resident #363. The RN stated that Resident #363 was originally admitted to the third floor unit in January and that Resident #363's January 2022 BMF may still be in that unit's binder. At 12:23 PM, the third floor Unit Manager provided Surveyor #2 Resident #363's January 2022 Behavior Monitoring Form. Surveyor #2 then reviewed Resident #363's BMF for January 2022 which included the following information: One form with no medication listed under Psychoactive Medication had indicated that the behavioral symptoms of yelling and screaming was to have been monitored daily on all three shifts starting 1/14/22 (day after admission). A review of the form reflected that the symptoms of yelling and screaming was only documented for the 7 AM to 3 PM shift on 1/15/22. The remaining 7 AM to 3 PM shifts from January 16 through January 31 were blank (not documented). The 3 PM to 11 PM and 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. There was no evidence that the facility documented Resident #363's behavior monitoring daily on all three shifts for the days the resident resided at the facility during January 2022. Surveyor #2 then reviewed Resident #363's electronic health record (EHR) for the January 2022 Monthly [CONDITION(S)] Note. There was no January 2022 Monthly [CONDITION(S)] Note in the EHR. On 2/17/22 at 12:59 PM, during surveyor interview, the Director of Nursing stated that Resident #363 should have had a Monthly [CONDITION(S)] Note done for January 2022. She added that the Monthly [CONDITION(S)] Note should be done by the fifteenth of the month. A review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring with a revised date of March 2019 included the following: Policy Statement 1. The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment 6. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Policy Interpretation and Implementation Management 10. When medications are prescribed for behavioral symptoms, documentation will include: . e. Specific target behaviors and expected outcomes; . h. Monitoring for efficacy and adverse consequences . Monitoring 1. If the resident is being treated for altered behavior or mood, the IDT (interdisciplinary team) will seek and document any improvements or worsening in the individual's behavior, mood and function. 2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. A review of the facility provided, Charting and Documentation policy and procedure, revised 7/17, included but was not limited to policy statement: all services provided to the resident, progress toward the care plan goals, or changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Interpretation and implementation: 2. the following information is to be documented in the resident medical record: a. objective observations; b. medications administered; c. treatments or services performed; d. changes in the resident's condition; 3. events, incidents or accidents involving the resident; and f. progress toward or changes in the care plan goals and objectives. A review of the facility policy titled, Tapering Medications and Gradual Drug Dose Reduction with a revised date of April 2007, included the following: The Attending Physician and staff will identify target symptoms for which a resident is receiving various medications. The staff will monitor for improvement in those target symptoms, and provide the Physician with that information . The staff and practitioner will monitor side effects closely for antidepressant. When a medication is tapered or stopped, the staff will closely monitor the resident and will inform the Physician if there is a return or worsening of symptoms. The facility did not provide the surveyors a policy regarding the Behavioral Monitoring Forms or the Monthly [CONDITION(S)] Note. NJAC 8:39 27.1 (a), 29.3(a) 3. On 2/16/2022 at 9:46 AM, surveyor #5 observed Resident #89 in bed in their room. The surveyor reviewed the medical record for Resident #89. A review of the Admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anxiety disorder, [CONDITION(S)], [CONDITION(S)] disorder, and [CONDITION(S)]. A review of the quarterly Minimum Data Set (MDS), dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 9 out of 15, which indicated moderately impaired cognition. A further review of the MDS, indicated that the resident exhibited no behavioral symptoms and received antipsychotic medications on 7 out of the last 7 days during the look back period. A review of the resident's individualized, comprehensive care plan dated 12/24/2020 included a care concern that the resident received antipsychotic medication related to [CONDITION(S)], pervasive developmental disorder, and autism. Interventions included to monitor for the effectiveness of the medication and to monitor for signs and symptoms of adverse reactions to the medication every shift. A review of the POS indicated an order dated 6/8/2021 for [MEDICATION(S)] (a medication used to treat [CONDITION(S)]) 3 milligrams 1 tablet by mouth two times a day. The Order Summary Report indicated that [MEDICATION(S)] was an active order, and that Resident #89 was still ordered to receive the medication. On 2/16/2022 at 10:20 AM, the surveyor reviewed the BMF(s) for Resident #89. The review indicated incomplete behavior monitoring in November 2021 with no monitoring occurring on any 7 AM- 3 PM shifts or on any 3 PM- 11 PM shifts. The review failed to indicate any BMF for December 2021. The review indicated an incomplete BMF for January 2022 with no monitoring occurring on any 11 PM to 7 AM shifts. The review failed to indicate any BMF for February 2022. The BMF for November 2021 listed Resident #89's behavioral symptom as yelling. The BMF for January 2022 listed Resident #89's behavioral symptom as delusions. The [CONDITION(S)] Note Monthl

Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to maintain a residents wheelchair and cushion in a clean and homelike manner. This deficient practice was identified for 1 of 3 residents reviewed for care of equipment and maintenance, Resident #63 and was evidenced by the following: The surveyor toured the 400's Unit on 2/11/2022 at 11:30 AM and observed Resident #63 siting on the bed, he/she did not acknowledged the surveyor when the surveyor entered the room. Next to the bed the surveyor observed a ripped and torn wheelchair, the cushion was torn in several places exposing the yellow foam. Some particles and food like debris were noted on the torn cushion. On 2/14/2022 at 11:45 AM, the surveyor observed Resident #63 sitting in the room, the wheelchair was noted at the bedside, ripped and torn in different places. The cushion was ripped and also torn in different areas. The surveyor reviewed Resident #63's medical record on 2/26/2022. The Admission Face Sheet revealed that Resident #63 was admitted to the facility with diagnoses which included but not limited to Alzheimer's Disease, Depression and [CONDITION(S)], acquired absence of right leg below knee, and acquired absence of left leg below knee. A review of the Quarterly Minimum Data Set (MDS) an assessment tool used to prioritize care, dated 11/18/21, coded Resident #63 as being severely cognitively impaired with a score of 03 out of 15 on the Brief Interview for Mental Status (BIMS). On 2/15/22 at 11:05 AM, an interview with the Unit Manager Registered Nurse (UM/RN) revealed that housekeeping power washed the wheelchairs every Monday but she was not aware that the wheelchair needed to be repaired. On 2/15/22 at 11:19 AM, the surveyor interviewed the Physical Therapy (PT) Director regarding Resident #63's wheelchair's condition. He stated that he was not aware of the wheelchair condition. He stated that he attended daily morning meeting and was never informed of the wheelchair condition. The surveyor showed the wheelchair's picture to the PT Director who stated that, it was unacceptable and that he would take care of it. On 2/16/2022 at 10:00 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for the resident. The CNA stated that Resident #63 was able to assist with care and that he/she was able to use the wheelchair independently. The surveyor observed Resident #63's wheelchair and cushion still in the same condition. The wheelchair was ripped and torn in different parts. On 2/16/2022 at 11:55 AM, the surveyor interviewed the unit Licensed Practical Nurse (LPN) who stated that staff were supposed to inform maintenance and housekeeping if something was broken or needed cleaning. The LPN had no explanation for why this equipment was not brought to the attention of maintenance and housekeeping. During a pre-exit conference with the facility administrative staff on 2/23/2022 at 10:40 AM, the Director of Nursing (DON) indicated that the wheelchair cushion was immediately removed and the staff was in -serviced on reporting on any damaged/ broken equipment. On 2/16/2022 at 9:09 AM, the DON provided the policy titled, Cleaning and Disinfection of Resident- Care Items and Equipment The policy Statement indicated the following: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The policy did not addressed wheelchair replacement. NJAC 8: 39 -31.4 ( c)

Based on interview, record review and review of facility provided documentation, it was determined that the facility failed to complete a Comprehensive Admission 14-day Minimum Data Set (MDS) assessment or Comprehensive Annual MDS assessment as required according to the Resident Assessment Instrument (RAI) for 5 of 24 residents reviewed for MDS completion (Resident #2, #4, #5, #8 and #363). The deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status and not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. On 2/15/22, the surveyor reviewed the MDS assessments, an assessment tool used to facilitate the management of care, for the timeliness of submission for 23 system-selected residents. Information provided by the facility revealed the following for the 5 residents: 1. Resident #2 had an Assessment Reference Date (ARD) of 12/8/21. The assessment was not completed until 2/9/22. 2. Resident #4 had an ARD of 12/29/21. The assessment was not completed until 2/14/22. 3. Resident #5 had an ARD of 12/19/21. The assessment was not completed until 2/14/22. 4. Resident #8 had an ARD of 12/29/21. The assessment was not completed until 2/14/22. 5. Resident #363 had an ARD of 1/20/22. The assessment was not completed until 2/15/22. On 2/15/22 at 10:31 AM, the surveyor interviewed the MDS Coordinator who stated that there was 14 days to complete the assessment after the ARD. She then confirmed that she had not completed the five MDS. She stated that she was trying to catch up with the assessments when she started in October after the last MDS coordinator left. On 2/23/22 at 10:09 AM, during surveyor interview, the Director of Nursing (DON) confirmed that the MDS assessments were not done and that they should have been completed in 14 days. A review of the facility provided policy titled, Resident Assessment Policy and Procedure dated 2020, included the following: Purpose and Policy. To ensure that .upon a resident's admission and periodically thereafter, conducts a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. Procedure . II. Comprehensive assessment/Resident assessment instrument. A. The Facility shall make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS B. Timeframe for conducting resident assessments. The Facility shall conduct comprehensive assessment of residents: a. Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition . c. Not less often than once every 12 months. d. The facility may be subject to additional state requirements and timelines. N.J.A.C. 8:39-11.2

Based on interview, record review and review of facility provided documents, it was determined that the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment, a periodic and federally mandated, standardized assessment tool, within the required time frame, according to the Resident Assessment Instrument (RAI) for 15 of 24 residents reviewed for MDS completion (Resident #1, #3, #6, #7, #9, #10, #11, #19, #23, #25, #27, #28, #29, #30 and #50). The deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS was within 92 days after the ARD of the previous MDS and; 2). the completion date was no later than 14 days after the ARD. On 2/15/22, the surveyor reviewed the MDS's, an assessment tool used to facilitate the management of care, for the timeliness of completion for 1 new admission resident and 23 system-selected residents. Information provided by the facility revealed the following for the 15 residents: 1. Resident #1 had an Assessment Reference Date (ARD) of 12/31/21. The assessment was not completed until 2/14/22. 2. Resident #3 had an ARD of 12/28/21. The assessment was not completed until 2/14/22. 3. Resident #6 had an ARD of 12/19/21. The assessment was not completed until 2/14/22. 4. Resident #7 had an ARD of 12/19/21. The assessment was not completed until 2/14/22. 5. Resident #9 had an ARD of 12/26/21. The assessment was not completed until 2/15/22. 6. Resident #10 had an ARD of 12/24/21. The assessment was not completed until 2/15/22. 7. Resident #11 had an ARD of 12/23/21. The assessment was not completed until 2/14/22. 8. Resident #19 had an ARD of 12/29/21. The assessment was not completed until 2/14/21. 9. Resident #23 had an ARD of 12/28/21. The assessment was not completed until 2/15/22. 10. Resident #25 had an ARD of 1/4/22. The assessment was not completed until 2/15/22. 11. Resident #27 had an ARD of 1/4/22. The assessment was not completed until 2/15/22. 12. Resident #28 had an ARD of 1/4/22. The assessment was not completed until 2/15/22. 13. Resident #29 had an ARD of 1/7/22. The assessment was not completed until 2/16/22. 14. Resident #30 had an ARD of 1/7/22. The assessment was not completed until 2/15/22. 15. Resident #50 had an ARD of 1/9/22. The assessment was not completed until 2/15/22. On 2/15/22 at 10:31 AM, the surveyor interviewed the MDS Coordinator who stated that there was 14 days to complete the assessment after the ARD. She then confirmed that she did not complete the MDS. She stated that she was trying to catch up with the assessments when she started in October after the last MDS coordinator left. On 2/23/22 at 10:09 AM, during surveyor interview, the Director of Nursing confirmed that the MDS assessments were not done and that they should have been completed in 14 days. A review of the facility provided policy titled, Resident Assessment Policy and Procedure dated 2020, included the following: Purpose and Policy. To ensure that .upon a resident's admission and periodically thereafter, conducts a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. Procedure . III. Quarterly review assessment. The Facility shall assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months. N.J.A.C. 8:39-11.2

Based on observation, interview and record review, it was determined that the facility failed to provide personal grooming care to a resident that was dependent on the staff for hygiene for 1 of 23 residents, Resident #63. This deficient practice was evidenced by the following: On 2/17/22 at 10:19 AM, the surveyor observed Resident #63 in the room, awake and was seated on the bed. The resident did not look at the surveyor or speak when spoken to. The resident's fingernails on both hands were long and extended beyond the fingertips. The surveyor also observed Resident #63 with a long, scattered facial hair. The surveyor reviewed the admission record that indicated Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate care management dated 11/18/21, indicated a Brief Interview for Mental Status scored at 03, which indicated that the resident had severely impaired cognition. The surveyor reviewed the interdisciplinary progress notes from November 2021 through February 2022 which reflected that there was no documentation for any refusal of hygiene personal care. On 2/17/22 at 10:21 AM, the surveyor spoke to the Licensed Practical Nurse (LPN) assigned to the resident who stated that Resident #63 was non-compliant with hygienic care. The surveyor interviewed the Certified Nursing Assistant (CNA) who stated that part of her responsibility during the morning rounds, included but was not limited to check resident's facial hair and nails. The LPN and the CNA both agreed that the resident's facial hair and fingernails were long and needed to be shaved and trimmed. A review of the facility's policy titled, Resident Care revealed that the purpose of the procedure was to ensure that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. On 2/22/22 at 12:30 PM, the surveyor discussed the above concern to the Administrator, Regional Nurse and Director of Nursing. The DON also agreed that the facial hair and the fingernails of Resident #63 needed to be trimmed. No further information was provided. NJAC 8:39 - 27.2 (g)

C# NJ , NJ Based on observation, interview and record review, it was determined that the facility failed to provide and/or maintain, identified safety devices that were being used to prevent falls. This deficient practice posed a serious and immediate jeopardy to all residents assessed to be at risk for falls. This deficient practice was identified for 18 out of 18 residents assessed as a risk for falls and also with physician orders [REDACTED].#18.)This deficient practice is evidenced by the following: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 9/23/11, the resident was alert and oriented, needed limited assistance with one person physical assist for transfers, not steady during transfer. The resident plan of care dated 6/22/11, documented under Problem/Need; "Resident ...at risk for fall. Fall risk assess high risk for fall" and documented under Approaches/Interventions; ... "Alarm on bed chair check for proper placement". The care plan was updated with target dates of 9/11, 12/11, 2/12 and 5/12. The "physician's orders [REDACTED]. These orders were reviewed on 1/2012 and 2/2012. The Fall Risk Assessment with assessment dates of 9/29/11 and 10/29/11, indicated a score of 11, and that a "Total score of 10 or above represents high risk". Although a review of the Treatment Administration Record (TAR) dated 3/1/12, 11-7 shift, documented "Tabs alarm in wheelchair check placement & function every shift and Chair alarm on wheelchair" that indicated that these devices were in place and checked, Resident #7 was observed by the surveyor in a wheelchair at 10:20 AM, during a tour with the Unit Manager(UM) and had no chair alarm present. 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, an assessment tool dated 2/2/12, the resident was alert and oriented, needed limited assistance with one person physical assist transfer, not steady during transfer. The resident plan of care dated 6/21/11 documented under Problem/Need; "Resident ...will avoid falls or otherwise injure self". Included under Approaches/Interventions; "Resident have refuse Tab alarm of wheelchair despite of encouragement to". The care plan was updated with target dates of 1/12 and 3/12. The POF dated 3/2011 included orders for 3/21/11, "Tab alarm on at all times when out of bed to wheelchair". These orders were reviewed on 1/2012 and 2/2012. The Fall Risk Assessment with assessment dates of 9/17/11 and 12/25/11 indicated a total score of 12. On 3/1/12 at 10:20 AM, during a tour with the UM, the surveyor observed Resident #8 in a wheelchair and had no tab alarm present, nor was it documented anywhere that the resident is encouraged to use the alarm but refuses to wear it. 3. Resident #9 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the MDS dated [DATE], the resident is alert and oriented with periods of confusion, independent with transfers with minimal physical assistance. The resident plan of care dated 6/30/11 indicated under Problem/Need; "Resident ... is at risk for falls: secondary to use psyche Rx, Dx! Seizure H/O falls and dizziness". Included under Approaches/Interventions; ... "Tab alarm on bed check for placement & functioning q (every) shift". This was updated with target dates of 2/12 and 4/12. The POF orders included; "...Devices Treatment ... 3/9/2011 Bed alarm sensor at all times. Check function every shift. 3/9/2011 Tabs alarm in wheelchair check functioning every shift". These orders were reviewed on 1/2012 and 2/2012. The Fall Risk Assessment with assessment dates of 9/29/11 and 10/29/11 had a total score of 11. On 3/1/12 at 10:20 AM, while on tour with the UM, the surveyor observed Resident #9 in bed. The resident had no bed alarm sensor or tab alarm present. However, the TAR dated 3/1/11, 11-7 shift, had a signed initial in each of the following boxes; "Bed alarm sensor at all times. Check function every shift and Tab alarm in wheelchair check functioning every shift, which indicated that these devices are in place and checked". 4. Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the 2/14/12 MDS, the resident was alert with short and long term memory minimally impaired, total dependence transfer with two person physical assist, not steady. The most recent resident plan of care dated 2/8/12 states under Problem/Need, "Fall & injuries. At risk for falls/injuries secondary Dx of seizure disorder". Included for Approaches/Interventions were; "Bed sensor while in bed. Tab alarm to wheelchair while in the chair. Check for placement and functioning of the alarms". The care plan was updated with a target date of 5/12. The POF orders included; "...Devices Treatment ... 3/21/2011 Bed Sensor on at all times when in bed check placement and function every shift. Tab alarm to wheelchair while OOB". These orders were reviewed on 1/2012 and 2/2012. The Fall Risk Assessment for Resident #10, with assessment dates of 11/18/11 and 2/11/12, had a total score of 12. On 3/1/12 at 10:20 AM, on tour with the UM, Resident #10 was observed in the wheelchair and had no bed sensor or chair alarm present. 5. Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the 12/4/11 MDS assessment tool, the resident was alert with short and long term memory minimally impaired, was totally dependent for transfer with two person physical assist. The resident plan of care dated 8/25/11 states under Problem/Need; "Resident ... at risk for fall: Resident poor safety awareness cognitive deficit Dx: Alzheimer" and states under Approaches/Interventions; ... "Tab alarm for wheelchair check placement and function qs (every shift)." The care plan was updated with target dates of 11/11 and 3/12. The POF for Resident #11 had physician's orders [REDACTED]. This order was documented as reviewed on 1/2012 and 2/2012. The Fall Risk Assessment with assessment dates of 9/13/11 and 12/4/11, give a total score of 10. During a tour on 3/1/12 at 10:20 AM, accompanied by the UM, Resident #11 was observed by the surveyor, in a wheelchair without a tab alarm present. 6. Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the 4/25/11 MDS assessment tool, the resident was alert and oriented to familiar faces, needed extensive assistance with transfers with two person physical assist. The resident plan of care dated 2/8/10, indicated that "Resident ... is risk for falls due to poor safety awareness". Included in the Approaches/Interventions were; "Chair alarm/tabs alarm on wheelchair - check placement & function qs". A review of the POF Orders for 2/2010 revealed orders for; "...Devices Treatment ... 2/8/2010 Chair Alarm/Tabs alarm on wheelchair - check for placement and function every shift". These orders were documented as reviewed on 1/2012 and 2/2012. The Fall Risk Assessment for Resident #12, with an assessment date of 9/7/11, gives a total score of 12. On 3/1/12 at 10:20 AM, while on tour with the UM, Resident #12, was observed by the surveyor. The resident was in bed and there was no bed or chair alarm present. However, the TAR dated 3/1/11, 11-7 shift, had signed initials documenting that "Chair alarm/Tabs alarm on wheelchair - Check for placement and function every shift". 7. Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the 2/1/12 MDS, the resident was alert and oriented, totally dependent for transfers with two person physical assist. The resident's plan of care dated 8/5/11 stated under Problem/Need; "Resident ... is at risk for fall/injury. Hx of fall secondary to weakness. Dx: CVA/Stroke". Care plan interventions included; "Alarms when in bed & chair. Check proper placement & function at all times". This care plan was updated with target dates of 11/11 and 2/12. The POF for Resident #13 had physicians orders for "...Devices Treatment ... 3/17/2011 Tabs alarm when out of bed to wheelchair - check placement & function every shift, 3/17/2011 Bed sensor at all times when in bed check function & placement every shift". These orders were reviewed on 1/2012 and 2/2012. The Fall Risk Assessment for Resident #13, dated of 10/27/11, gives a total score of 12. On 3/1/12 at 10:20 AM, on tour with the UM, Resident #13 was observed in a wheelchair and had no bed sensor or chair alarm present. However, the TAR dated 3/1/11, 11-7 shift, had a signed initial in each of the following boxes, "Tabs alarm when out of bed to wheelchair - check placement & function every shift and Bed Sensor at all times when in bed check function & placement every shift". 8. Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the 2/2/12 MDS, the resident was alert and oriented with periods of confusion, required extensive assistance transfer with two person physical assist. The interdisciplinary team meeting form progress notes dated 2/9/12 states, "#11 Falls will proceed due to Resident need for human assistance to stabilize himself during transfer". The POF orders dated 3/21/2011, included "Bed alarm on right at all times when in bed check function and placement every shift". These orders were reviewed on 1/2012 and 2/2012. The Fall Risk Assessment with assessment date of 12/2/11 gives a total score of 10. During a tour of the unit on 3/1/12 at 10:20 AM with the UM, Resident #14 was observed by the surveyor to be in bed without a bed alarm present. However, it was documented on the TAR dated 3/1/11, 11-7 shift, that the alarm was in place. 9. Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS assessment tool revealed that the resident was alert and oriented, and needed supervision transfer with help. The resident plan of care dated 5/30/11 states under Problem/Need, "Resident ... is at risk for falls due to generalized deconditioning. Resident ... fall at home prior to here". This was updated with target dates of 8/11, 11/11 and 2/12. The physician's orders [REDACTED]. These orders were reviewed on 1/2012 and 2/2012. The Fall Risk Assessment with an assessment date of 12/10/11 gives a total score of 9. Although the TAR dated 3/1/11, 11-7 shift, had documentation indicating that alarms were in place as ordered by the physician, Resident # 15 was observed in a wheelchair, without a chair alarm, during a tour accompanied by the UM on 3/1/12 at 10:20 AM. The resident also did not have a bed sensor alarm on the resident's bed, nor was there any evidence that an alarm was available in the room. 10. Resident #16 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the 12/2/11 MDS the resident was alert and oriented, needed limited assistance for transfer with one person physical assist. The resident's plan of care dated 10/27/11 revealed that the resident was at risk for fall had a history of [REDACTED]. The interventions for Resident # 16 included a Tab alarm on the wheelchair and that the alarm function be checked as well as placement every shift. This was updated with target dates of 1/12 and 3/12. The physician order [REDACTED]. These orders were reviewed on 1/2012 and 2/2012. The Fall Risk Assessment with assessment dates of 11/13/11 and 2/12/12 each were a total score of 8. On 3/1/12 at 10:20 AM, on tour with the Unit Manager, Resident #16 was observed in a wheelchair without a chair alarm present. However, the TAR dated 3/1/11, 11-7 shift, had signed initials in the following box, "Tabs alarm on at all times when in wheelchair check function & placement every shift" indicating that the alarm was in place. 11. Resident #17 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the 11/30/11 MDS, the resident was alert and oriented with periods of confusion, needed extensive assistance with transfers with two person physical assist. The resident plan of care dated 6/14/11 revealed that the resident is at risk for fall due to generalized weakness and had a history of [REDACTED]. Interventions on the plan of care included a Tab alarm in the wheelchair. The care plan was updated with target dates of 9/11, 12/11, and 3/12. The POF dated 3/21/2011, had a physician order [REDACTED]. These orders were documented as reviewed on 1/2012 and 2/2012. The Fall Risk Assessment with assessment dates of 12/2/11 and 3/1/12 each had a total score of 8. On 3/1/12 at 10:20 AM, during a tour with the UM, Resident #17 was observed in a wheelchair without a chair alarm present. However, the TAR dated 3/1/11, 11-7 shift, had a signed initial in the following box, "Tabs alarm when out of bed to wheelchair - check placement & function every shift". 12. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 12/7/11 MDS, the resident was alert with periods of confusion and required assistance with activities of daily living. The Interim Care Plan, dated 2/17/12, identified the resident at risk for falls with interventions that included chair alarm and bed sensor in place. According to the Fall Risk Assessment, dated 2/20/12, the resident had a score of 11. A score of 10 or above indicates high risk for falls. Review of the resident's POF, revealed an order on 2/17/12, for a chair alarm and 2/18/12, for a bed sensor while in bed. On 3/1/12 at 10:30 AM, on tour of the third floor with the Unit Manager (UM), no bed alarm was present on Resident #1's bed. There was no evidence that an alarm was available in the resident's room. However, the TAR dated 3/1/12, 11-7 shift had a signed initial documenting that the bed sensor alarm was on the bed. In an interview with the surveyor during the tour, the UM stated that the resident should have a chair alarm but did not think he had a bed alarm ordered. 13. Resident # 2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 11/4/11 MDS, the resident was confused and required assistance with activities of daily living. The Resident Plan of Care dated 11/17/11, identified the resident at risk for falls, related to unsteady gait and lack of safety awareness. Interventions included a bed sensor alarm. According to the Fall Risk Assessment on admission, the resident had a score of 18. Review of the POF for March 2012, revealed an order on 10/28/10, for a personal alarm on the bed and to check function every shift. A review of Interdisciplinary Progress Notes, revealed that the resident sustained [REDACTED]. On 3/12/12 at 10:30 AM, on tour of the third floor with the UM, Resident # 2 had no bed alarm present and there was no evidence that an alarm was available in the resident's room. However, the TAR dated 3/1/12, 11-7 shift, had signed initials documenting that the personal alarm was on the bed and that the functioning of the alarm was checked. In an interview with the surveyor during tour, the UM stated that the resident does not have a bed alarm because he is ambulatory. 14. Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 11/30/11 MDS, the resident was alert and oriented and required assistance with activities of daily living. According to the Fall Risk assessment dated [DATE], the resident had a score of 12. A review of the resident's POF, revealed an order on 8/1/11, for a tab alarm and bed sensor alarm and to check for placement and functioning every shift. On 3/1/12 at 10:30 AM, on tour with the UM of the third floor, Resident # 3 had no tab alarm on his wheel chair and no bed sensor alarm on the bed. There was no evidence that alarms were available in the resident's room. However, the TAR dated 3/1/12, the 11-7 shift had a signed initial documenting that the alarms were in place and functioning. 15. Resident # 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 1/5/12 MDS, the resident had severe cognitive impairment and required extensive assistance with activities of daily living. According to the Fall Risk assessment dated [DATE], the resident had a score of 13. A review of the resident's POF, revealed an order on 11/10/11 for a bed sensor alarm, check placement and functioning every shift. The Resident's Plan of Care dated 11/10/11, identified the resident at risk for falls, with a history of falls prior to admission. Interventions included a tab alarm to the wheel chair but no documentation of the bed alarm ordered by the physician. On 3/1/12 at 10:30 AM on tour with the third floor UM, Resident # 4 had no bed alarm on her bed, nor was there evidence that an alarm was available in the room. However, the TAR dated 3/1/12, 11-7 shift had a signed initial documenting that the bed sensor alarm was on the bed and was functioning. 16. Resident # 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 10/27/11 MDS, the resident was severely cognitively impaired and required assistance with activities of daily living. The Resident's Plan of Care dated 11/22/11, identified the resident at risk for falls due to unsteady gait and history of falls prior to admission. Interventions included a chair alarm and a bed sensor alarm. According to the Fall Risk assessment dated [DATE], the resident had a score of 14. Review of the resident's POF, revealed an order on 10/21/11 for a bed sensor alarm, to be checked for placement and functioning every shift. On 3/1/12, on tour with the third floor UM, Resident # 5 had no bed sensor alarm on her bed. There was no evidence that an alarm was available in the resident's room. However, the TAR dated 3/1/12, 11-7 shift had a signed initial documenting that the alarm was in place and functioning. 17. Resident # 6 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the 11/17/11 MDS, the resident had long and short term memory impairment and required assistance with activities of daily living. The Resident's Plan of Care dated 6/16/11, identified the resident at risk for falls due to unsteady gait. Interventions included bed alarm in bed and check the functioning of the alarm. According to the Fall Risk assessment dated [DATE], the resident had a score of 19. Although a review of the TAR dated 3/1/12, 11-7 shift, documented "Check bed alarm while in bed every shift" that indicated that these devices were in place and checked, Resident #6 was observed by the surveyor in bed at 10:20 AM, during a tour with the UM and had no bed alarm in place. 18. Resident # 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 11/21/11, MDS, the resident had severe cognitive impairment and required assistance with activities of daily living. According to the Fall Risk assessment dated [DATE], the resident had a score of 14. Review of the resident's POF revealed an order dated 3/15/11 for a sensor alarm in bed. On 3/1/12, on tour with the third floor UM, Resident # 18 had no bed alarm present, nor was there any evidence that an alarm was available in the room. However, the TAR dated 3/1/12, 11-7 shift had a signed initial documenting that the alarm was in place. In an interview with the surveyor during tour, the UM stated that he doesn't have an alarm on the bed, because he doesn't get up. Review of the facility Fall Policy dated January 2006, states, each resident receives adequate supervision and assistive devices to prevent accidents. On admission all residents are assessed for risk for falls by nursing. Nursing will initiate appropriate interventions for fall prevention as needed. These interventions include, chair and bed alarms..... The Immediate Jeopardy was identified on 3/1/12 at 1:45 PM. The facility administrator was notified of the situation. The facility administrator presented an acceptable Plan of Correction which lifted the Immediate Jeopardy. No further POC is required. The plan of correction submitted on day of survey included the following: 1. All residents classified at a risk for falls have had the proper alarms implemented and checked for proper operation. 2. Care Plans will be updated to reflect alarm implementation. 3. Immediate inservicing for all nursing staff will have been completed on all shifts on the proper use of alarms today. 4. A list of residents who have alarms will be generated and will be reviewed on a weekly basis and as needed to ensure accuracy. This list will be reviewed by the Safety Committee, including the Administrator, DON, ADON and Rehabilitation Services Director. 5. The Quality Assurance CNA's will ensure that the CNA's assigned to residents who have alarms have the alarms placed properly and are functioning. 6. Nursing staff will ensure proper implementation throughout the day as regular rounds are completed. 7. Evening and Weekend Supervisors will act as designees and check for proper implementation in the absence of the DON and Administrator. 8. Spot checks will be conducted by the Weekend Manager on Duty as well as the Department Director "night Owl" to ensure alarms are working correctly and that staff responds accordingly. 9. The fall cart of the 2nd floor will be checked daily to ensure it is stocked correctly. 10. All staff that have not followed proper policy and procedure in the implementation of bed and chair alarms will be disciplined accordingly, including suspension and/or termination, depending on the severity of the violation. NJAC 8:39-27.1(a)

C# NJ , NJ Based on observation, interview, and record review, it was determined that the facility failed to provide and/or maintain, as well as consistently implement per physicians orders, identified safety devices to prevent falls. This deficient practice posed a serious and immediate jeopardy to all residents assessed to be at risk for falls. This deficient practice was identified for 18 out of 18 residents surveyed with physician orders [REDACTED].#18.)This deficient practice is evidenced by the following: Reference: New Jersey State Nurse Practice Act Title 45 Chapter 11 45-23 definition: The practice of nursing as a registered professional nurse is defined as ... executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. Resident # 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 12/7/11 MDS, the resident was alert with periods of confusion and required assistance with activities of daily living. The Interim Care Plan, dated 2/17/12, identified the resident at risk for falls with interventions that included chair alarm and bed sensor in place. A review of the resident's Physician order [REDACTED]. On 3/1/12 at 10:30 AM, on tour of the third floor with the Unit Manager (UM), no bed alarm present on Resident #1's bed. There was no evidence that an alarm was available in the resident's room. However, the Treatment Administration Record (TAR) dated 3/1/12, 11-7 shift had a signed initial documenting that the bed sensor alarm was on the bed, as ordered by the physician. In an interview with the surveyor during the tour, the UM stated that the resident should have a chair alarm but did not think he had a bed alarm ordered. 2. Resident # 2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 11/4/11 MDS, the resident was confused and required assistance with activities of daily living. The Resident Plan of Care dated 11/17/11, identified the resident at risk for falls, related to unsteady gait and lack of safety awareness. Interventions included a bed sensor alarm. A review of the POF for March 2012, revealed an order on 10/28/10, for a personal alarm on the bed and to check function every shift. On 3/12/12 at 10:30 AM, on tour of the third floor with the UM, Resident # 2 had no bed alarm present and there was no evidence that an alarm was available in the resident's room. However, the TAR dated 3/1/12, 11-7 shift, had signed initials documenting that the personal alarm was on the bed and that the functioning of the alarm was checked, as ordered by the physician. In an interview with the surveyor during tour, the UM stated that the resident does not have a bed alarm because he is ambulatory. 3. Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 11/30/11 MDS, the resident was alert and oriented and required assistance with activities of daily living. A review of the resident's POF, revealed an order on 8/1/11, for a tab alarm and bed sensor alarm and to check for placement and functioning every shift. On 3/1/12 at 10:30 AM, on tour with the UM of the third floor, Resident # 3 had no tab alarm on his wheel chair and no bed sensor alarm on the bed. There was no evidence that alarms were available in the resident's room. However, the TAR dated 3/1/12, the 11-7 shift had a signed initial documenting that the alarms were in place and functioning, as ordered by the physician. 4. Resident # 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 1/5/12 MDS, the resident had severe cognitive impairment and required extensive assistance with activities of daily living. A review of the resident's POF, revealed an order on 11/10/11 for a bed sensor alarm, check placement and functioning every shift. The Resident's Plan of Care dated 11/10/11, identified the resident at risk for falls, with a history of falls prior to admission. Interventions included a tab alarm to the wheel chair but no documentation of the bed alarm. On 3/1/12 at 10:30 AM on tour with the third floor UM, Resident # 4 had no bed alarm on her bed, nor was there evidence that an alarm was available in the room. However, the TAR dated 3/1/12, 11-7 shift had a signed initial documenting that the bed sensor alarm was on the bed and was functioning, as ordered by the physician. 5. Resident # 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 10/27/11 MDS, the resident was severely cognitively impaired and required assistance with activities of daily living. The Resident's Plan of Care dated 11/22/11, identified the resident at risk for falls due to unsteady gait and history of falls prior to admission. Interventions included a chair alarm and a bed sensor alarm. A review of the resident's POF, revealed an order on 10/21/11 for a bed sensor alarm, to be checked for placement and functioning every shift. On 3/1/12, on tour with the third floor UM, Resident # 5 had no bed sensor alarm on her bed. There was no evidence that an alarm was available in the resident's room. However, the TAR dated 3/1/12, 11-7 shift had a signed initial documenting that the alarm was in place and functioning, as ordered by the physician. 6. Resident # 6 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the 11/17/11 MDS, the resident had long and short term memory impairment and required assistance with activities of daily living. The Resident's Plan of Care dated 6/16/11, identified the resident at risk for falls due to unsteady gait. Interventions included bed alarm in bed and check the functioning of the alarm. A review of the POF, revealed an order dated 8/4/10, for a bed alarm and to be checked every shift. Resident #7 was observed by the surveyor in a wheelchair at 10:20 AM, during a tour with the UM and had no chair alarm present. Although a review of the TAR dated 3/1/11, 11-7 shift, documented "Tabs alarm in wheelchair check placement & function every shift and Chair alarm on wheelchair" that indicated that these devices were in place and checked, as ordered by the physician. 7. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident plan of care dated 6/22/11, documented under Problem/Need; "Resident ...at risk for fall. Fall risk assess high risk for fall" and documented under Approaches/Interventions; ... "Alarm on bed chair check for proper placement". The care plan was updated with target dates of 9/11, 12/11, 2/12 and 5/12. The resident's POF dated 6/2011, included physicians orders for 6/22/2011; "Tabs alarm in wheelchair check placement & function every shift, bed sensor alarm while in bed check placement & function every shift, chair alarm on wheelchair". These orders were reviewed on 1/2012 and 2/2012. Although a review of the TAR dated 3/1/11, 11-7 shift, documented "Tabs alarm in wheelchair check placement & function every shift and Chair alarm on wheelchair" that indicated that these devices were in place and checked, as ordered by the physician, Resident #7 was observed by the surveyor in a wheelchair at 10:20 AM, during a tour with the UM and had no chair alarm present. 8. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident plan of care dated 6/21/11 documented under Problem/Need; "Resident ...will avoid falls or otherwise injure self". Included under Approaches/Interventions; "Resident have refuse Tab alarm of wheelchair despite of encouragement to". The care plan was updated with target dates of 1/12 and 3/12. The POF dated 3/2011 included orders for 3/21/11, "Tab alarm on at all times when out of bed to wheelchair". These orders were reviewed on 1/2012 and 2/2012. On 3/1/12 at 10:20 AM, during a tour with the UM, the surveyor observed Resident #8 in a wheelchair and had no tab alarm present, as ordered by the physician, nor was it documented anywhere that the resident is encouraged to use the alarm but refuses to wear it. 9. Resident #9 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident plan of care dated 6/30/11 indicated under Problem/Need; "Resident ... is at risk for falls: secondary to use psyche Rx, Dx! [MEDICAL CONDITION] H/O falls and dizziness". Included under Approaches/Interventions; ... "Tab alarm on bed check for placement & functioning q (every) shift". This was updated with target dates of 2/12 and 4/12. The POF orders included; "...Devices Treatment ... 3/9/2011 Bed alarm sensor at all times. Check function every shift. 3/9/2011 Tabs alarm in wheelchair check functioning every shift". These orders were reviewed on 1/2012 and 2/2012. On 3/1/12 at 10:20 AM, while on tour with the UM, the surveyor observed Resident #9 in bed. The resident had no bed alarm sensor or tab alarm present. However, the TAR dated 3/1/11, 11-7 shift, had a signed initial in each of the following boxes;"Bed alarm sensor at all times. Check function every shift and Tab alarm in wheelchair check functioning every shift", which indicated that these devices are in place and checked, as ordered by the physician . 10. Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The most recent resident plan of care dated 2/8/12 states under Problem/Need, "Fall & injuries. At risk for falls/injuries secondary Dx of [MEDICAL CONDITION] disorder". Included for Approaches/Interventions were; "Bed sensor while in bed. Tab alarm to wheelchair while in the chair. Check for placement and functioning of the alarms". The care plan was updated with a target date of 5/12. The POF orders included; "...Devices Treatment ... 3/21/2011 Bed Sensor on at all times when in bed check placement and function every shift. Tab alarm to wheelchair while OOB". These orders were reviewed on 1/2012 and 2/2012. On 3/1/12 at 10:20 AM, on tour with the UM, Resident #10 was observed in the wheelchair and had no bed sensor or chair alarm present, as ordered by the physician. 11. Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident plan of care dated 8/25/11 states under Problem/Need; "Resident ... at risk for fall: Resident poor safety awareness cognitive deficit Dx: Alzheimer" and states under Approaches/Interventions; ... "Tab alarm for wheelchair check placement and function qs (shift)." The care plan was updated with target dates of 11/11 and 3/12. The POF for Resident #11 had physician orders [REDACTED]. This order was documented as reviewed on 1/2012 and 2/2012. During a tour on 3/1/12 at 10:20 AM, accompanied by the UM, Resident #11 was observed by the surveyor, in a wheelchair without a tab alarm present. 12. Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident plan of care dated 2/8/10, indicated that "Resident ... is risk for falls due to poor safety awareness". Included in the Approaches/Interventions were; "Chair alarm/tabs alarm on wheelchair - check placement & function qs". A review of the POF Orders for 2/2010 revealed orders for; "...Devices Treatment ... 2/8/2010 Chair Alarm/Tabs alarm on wheelchair - check for placement and function every shift". These orders were documented as reviewed on 1/2012 and 2/2012. On 3/1/12 at 10:20 AM, while on tour with the UM, Resident #12, was observed by the surveyor. The resident was in bed and there was no bed or chair alarm present. However, the TAR dated 3/1/11, 11-7 shift, had signed initials documenting that "Chair alarm/Tabs alarm on wheelchair - Check for placement and function every shift", as ordered by the physician. 13. Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's plan of care dated 8/5/11 stated under Problem/Need; "Resident ... is at risk for fall/injury. Hx of fall secondary to weakness. Dx: [MEDICAL CONDITION]/Stroke". Care plan interventions included; "Alarms when in bed & chair. Check proper placement & function at all times". This care plan was updated with target dates of 11/11 and 2/12. The POF for Resident #13 had physician's orders [REDACTED]. These orders were reviewed on 1/2012 and 2/2012. On 3/1/12 at 10:20 AM, on tour with the UM, Resident #13 was observed in a wheelchair and had no bed sensor or chair alarm present and none was available for use. However, the TAR dated 3/1/11, 11-7 shift, had a signed initial in each of the following boxes, "Tabs alarm when out of bed to wheelchair - check placement & function every shift and Bed Sensor at all times when in bed check function & placement every shift", as ordered by the physician. 14. Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The interdisciplinary team meeting form progress notes dated 2/9/12 states, "#11 Falls will proceed due to Resident need for human assistance to stabilize himself during transfer". The POF orders dated 3/21/2011, included "Bed alarm on right at all times when in bed check function and placement every shift". These orders were reviewed on 1/2012 and 2/2012. During a tour of the unit on 3/1/12 at 10:20 AM with the UM, Resident #14 was observed by the surveyor to be in bed without a bed alarm present and none was available for use. However, it was documented on the TAR dated 3/1/11, 11-7 shift, that the alarm was in place, as ordered by the physician. 15. Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident plan of care dated 5/30/11 states under Problem/Need, "Resident ... is at risk for falls due to generalized deconditioning. Resident ... fall at home prior to here". This was updated with target dates of 8/11, 11/11 and 2/12. The physician's orders [REDACTED]. These orders were reviewed on 1/2012 and 2/2012. Although the TAR dated 3/1/11, 11-7 shift, had documentation indicating that alarms were in place as ordered by the physician, Resident # 15 was observed in a wheelchair, without a chair alarm, during a tour accompanied by the UM on 3/1/12 at 10:20 AM. The resident also did not have a bed sensor alarm on the resident's bed, nor was there any evidence that an alarm was available in the room. 16. Resident #16 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's plan of care dated 10/27/11 revealed that the resident was at risk for fall had a history of [REDACTED]. The interventions for Resident #16 included a Tab alarm on the wheelchair and that the alarm function be checked as well as placement every shift. This was updated with target dates of 1/12 and 3/12. The physician order [REDACTED]. These orders were reviewed on 1/2012 and 2/2012. On 3/1/12 at 10:20 AM, on tour with the Unit Manager, Resident #16 was observed in a wheelchair without a chair alarm present. However, the TAR dated 3/1/11, 11-7 shift, had signed initials in the following box, "Tabs alarm on at all times when in wheelchair check function & placement every shift", as ordered by the physician, indicating that the alarm was in place. 17. Resident #17 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident plan of care dated 6/14/11 revealed that the resident is at risk for fall due to generalized weakness and had a history of [REDACTED]. Interventions on the plan of care included a Tab alarm in the wheelchair. The care plan was updated with target dates of 9/11, 12/11, and 3/12. The POF dated 3/21/2011, had a physician order [REDACTED]. On 3/1/12 at 10:20 AM, during a tour with the UM, Resident #17 was observed in a wheelchair without a chair alarm present. However, the TAR dated 3/1/11, 11-7 shift, had a signed initial in the following box, "Tabs alarm when out of bed to wheelchair - check placement & function every shift", as ordered by the physician. 18. Resident # 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 11/21/11, MDS, the resident had severe cognitive impairment and required assistance with activities of daily living. A review of the resident's POF revealed an order dated 3/15/11 for a sensor alarm in bed. On 3/1/12, on tour with the third floor UM, Resident # 18 had no bed alarm present, nor was there any evidence that an alarm was available in the room. However, the TAR dated 3/1/12, 11-7 shift had a signed initial documenting that the alarm was in place. In an interview with the surveyor during tour, the UM stated that he doesn't have an alarm on the bed, because he doesn't get up. The Immediate Jeopardy was identified on 3/1/12 at 1:45 PM. The facility administrator was notified of the situation. The facility administrator presented an acceptable Plan of Correction which lifted the Immediate Jeopardy. No further POC is required. The plan of correction submitted on day of survey included the following: 1. All residents classified at a risk for falls have had the proper alarms implemented and checked for proper operation. 2. Care Plans will be updated to reflect alarm implementation. 3. Immediate inservicing for all nursing staff will have been completed on all shifts on the proper use of alarms today. 4. A list of residents who have alarms will be generated and will be reviewed on a weekly basis and as needed to ensure accuracy. This list will be reviewed by the Safety Committee, including the Administrator, DON, ADON and Rehabilitation Services Director. 5. The Quality Assurance CNA's will ensure that the CNA's assigned to residents who have alarms have the alarms placed properly and are functioning. 6. Nursing staff will ensure proper implementation throughout the day as regular rounds are completed. 7. Evening and Weekend Supervisors will act as designees and check for proper implementation in the absence of the DON and Administrator. 8. Spot checks will be conducted by the Weekend Manager on Duty as well as the Department Director "night Owl" to ensure alarms are working correctly and that staff responds accordingly. 9. The fall cart of the 2nd floor will be checked daily to ensure it is stocked correctly. 10. All staff that have not followed proper policy and procedure in the implementation of bed and chair alarms will be disciplined accordingly, including suspension and/or termination, depending on the severity of the violation. NJAC 8:39-27.1(a)