Every finding on record at Complete Care at Green Acres

Based on record review, interview, policy review, and review of McGeer criteria, the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for one of four residents (Resident (R) 99) reviewed for antibiotic stewardship out of total sample of 32. This failure had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary.Findings include: Review of the facility's policy titled, Infection Surveillance, dated 09/01/2,4 indicated, A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections . The CDC's [Centers for Disease Control] National Healthcare Safety Network (NHSN) Long Term Care Criteria, updated McGeer criteria or other nationally-recognized [sic] surveillance criteria will be used to define infections . Review of R99's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R30 was admitted to the facility on [DATE] with the most recent diagnosis being heart failure. Review of R99's Nursing Progress Notes, located under the Progress Note tab in the EMR and dated 02/04/25 at 6:59 AM, indicated, . Patient stayed on w/chair [wheelchair] all night; X [times] 2 [sic] nights. MD [medical doctor] Dr. [doctor] notified via [by] text; awaiting response [sic]. Review of R99's Nursing Progress Notes, located under the Progress Note tab in the EMR and dated 02/07/25 at 9:46 AM, indicated, . labs referred, new order to start Bactrim [an antibiotic] DS [double strength] 1 [sic] tab po [by mouth] x7 [sic] days BID [twice a day], POA [Power of Attorney] made aware, order carried out . Review of R99's Urinalysis lab report, provided by the facility and with a collection date of 02/05/25 and a reported date of 02/07/25, revealed the urinalysis, microscopic was performed. Review of R99's Urine Culture lab report, provided by the facility and with a collection date of 02/05/25 and a reported date of 02/07/25, revealed results of the organism being Escherichia coli 50,000 to 100,000 colonies. Review of R99's untitled infection surveillance form, provided by the facility and dated 02/07/25, indicated the form was not filled out completely and the area marked was UTI criteria NOT met. During an interview on 07/31/25 at 5:30 PM, the Regional Clinical Director (RCD) and the Infection Preventionist (IP) confirmed the rationale of obtaining a urinalysis with culture and sensitivity should not have been patient staying up in her wheelchair all night even though they stated this was abnormal for the patient to do. NJAC 8:39-19.4(d)

Based on record review, interview, and document review, the facility failed to have a complete and accurate medical record for three out of 32 (Resident (R) 126, R164, and R191) sampled residents. This failure had the potential to adversely affect the care of these residents with inaccurate information in the medical record.Findings include: 1. Review of R126's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R126 was admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, and stroke. Review of R126's admission Minimum Data Set (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 06/04/25, indicated R126 had a Brief Interview of Mental Status (BIMS) score of five out of 15, which indicated R126 was severely cognitively impaired. Review of R126's Nursing Progress Notes, located under the Progress Note tab in the EMR, indicated on 07/17/25 at 2:49 PM, . During medication pass, patient noted to be lethargic, BP [blood pressure] 71/54, P [pulse] 86. Responds to verbal stimuli. Call placed to [name of medical doctor (MD)], informed of current status. Orders received . 12 PM [sic]patient seen by wound NP [nurse practitioner], patient noted with left facial droop, slow to respond. Call placed to [name of medical doctor (MD)], order received to send patient to [name of hospital] for eval [evaluation] . Review of R126's Notice of Emergency Transfer, provided by the facility and dated 07/17/25, indicated the reason for transfer was General Weakness. 2. Review of R164's undated Face Sheet, located under the Profile tab in the EMR, indicated R164 was admitted to the facility on [DATE] with diagnoses that included bilateral above the knee amputation. Review of R164's MDS could not be completed as the admission MDS had not been completed at the time of transfer to the hospital on [DATE]. Review of R164's Nursing Progress Notes, located under the Progress Note tab in the EMR, indicated on 06/08/25 at 12:40 PM, . Writer met with patient and spoke to daughter via [by] video call. [sic] regarding pain management and patient's constant complaint of pain 10/10 despite pharmacological and non-pharmacological interventions. Both expressed extreme desire to go back to the hospital as oral medications are not helping her mom's pain. [Name of MD] notified with orders to send patient out to [name of hospital] . Review of R164's New Jersey Universal Transfer Form, dated 06/08/25 and provided by the facility, indicated the reason for transfer was Unrelieved Pain - Lt [left] leg [sic]. Review of R164's Notice of Emergency Transfer, provided by the facility and dated 06/08/25, indicated the reason for transfer was for Evaluation. During an interview on 07/31/25 at 5:30 PM, the Social Services Director (SSD) stated, I read in the notes where the patient was admitted to the hospital and put the reason why the patient was admitted for the reason for transfer. During an interview on 07/31/25 at 5:30 PM, the Administrator stated, We are doing this paperwork in retrospect, and we thought the reason for admission was the reason the resident was being transferred to the hospital. Review of the facility's policy titled, Transfer and Discharge (including AMA [Against Medical Advice]), dated with a revision date of 03/10/25, indicated, . The facility's transfer/discharge notice will be provided to the resident and resident's representative. in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge . 3.Review of R191's undated Face Sheet, located under the Profile tab in the EMR, indicated R191 was admitted to the facility on [DATE] with diagnoses that included unstageable pressure ulcer of the sacral region. Review of R191's admission MDS, located under the MDS tab of the EMR and with an ARD of 05/19/25, indicated R191 had a BIMS score of six out of 15, which indicated R191 was severely cognitively impaired. There was no documentation of the unstageable pressure ulcer to the sacral region on this form. Review of R191's Nursing Progress Notes, located under the Progress Note tab in the EMR and dated 05/20/25 at 2:16 PM, indicated, . 2nd [sic] skin check -pressure sore noted to sacrum -redness noted to bony premises on back -dryness to BLE [bilateral lower extremities [sic] . During an interview on 07/31/25 at 2:29 PM, Licensed Practical Nurse (LPN) 2 stated, I should have documented the appearance of what I was seeing regarding the pressure sore. During an interview on 07/31/25 at 4:30 PM, the Director of Nursing (DON) stated, The nurse should document the description of the wound if the resident has one. Review of the facility's policy titled, Skin Assessment, dated 09/01/24, indicated . Documentation of skin assessment . Describe wound . NJAC 8:39-4.1(a)NJAC 8:39-35.2

Based on observation, interviews, and pertinent facility documentation on 07/09/2024, it was determined that the facility failed to ensure handwashing was performed according to their policy and acceptable standards of infection control practice according to the Centers for Disease Control and Prevention (CDC). This deficient practice was identified for 1 of 3 Employees (Certified Nursing Assistant #1 (CNA #1), observed for handwashing technique. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, last reviewed 1/8/2021, Healthcare Providers, When and How to Perform Hand Hygiene, Techniques for Washing Hands with Soap and Water, recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet Review of the facility line listing (LL) provided by the facility on 07/09/2024, showed that the Covid-19 outbreak was started on 06/23/2024 and the last person positive for COVID 19 was on 07/01/2024. During the tour of the Village Unit on 07/09/2024, the Surveyor observed the following. 1. On 07/09/2024 at 11:52 a.m., the Surveyor observed CNA #1 perform hand hygiene. CNA #1 turned the water on using the faucet knob, wet her hands, turned the water off using the faucet knob, applied soap to hands and performed friction motion with hands for 20 seconds, turned water on using the faucet knob, rinsed hands with water, turned water off using the faucet knob, retrieved a paper towel and dried her hands. This was not according to the facility's policy and CDC guidelines for health care providers. 2. On 07/09/2024 at 12:06 p.m., the Surveyor observed CNA #1 perform hand hygiene a second time. CNA #1 turned the water on using the faucet knob, applied soap to hands, turned off the water using the faucet knob, performed friction motion with hands for 20 seconds, turned the water on using the faucet knob, rinsed hands with water, turned the water off using the faucet knob, and dried her hands with a paper towel. This was not according to facility's policy and CDC guidelines for health care providers. During an interview with the Surveyor on 07/09/2024 at 12:09 p.m., CNA #1 stated that when she was washing her hands, she takes soap, [NAME] hands with soap for 20 seconds, and then puts water on. CNA #1 stated after rinsing hands, she turns water off, and then takes paper towel and dries her hands. CNA #1 stated she puts sanitizer on her hands after drying them. CNA #1 stated she received an in-service on handwashing by the Director of Nursing (DON) during the recent outbreak. CNA #1 stated she signed the in-service sheet. During an interview with the Surveyor on 07/09/2024 at 12:45 p.m., the Infection Preventionist (IP) stated the steps for handwashing included to get a paper towel, turn the water on, wet hands, put soap in hands, wash hands for 20 seconds, rinse hands, dry hands using paper towel already set out, and another paper towel to turn off faucet. IP stated a handwashing audit was done by the previous IP. IP stated that during the recent outbreak, she did not go over with staff the actual procedure for handwashing. IP stated, staff did sign in-service on what to do inside and outside of room during outbreak. During an interview with the Surveyor on 07/09/2024 at 3:18 p.m., the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and IP stated, handwashing included to turn water on, wet hands, apply soap, lather for 20 seconds, then rinse hands, get paper towel to dry hands and a separate paper towel to turn off faucet. DON stated that he does not expect staff to turn off faucet prior to drying hands. DON stated his expectation for all staff is to follow policies and procedures of facility. DON further stated, It is important for staff to follow proper handwashing for infection control. The certificate titled Relias Certificate of Completion dated 02/20/2024 revealed CNA #1 has successfully completed the course Basics of Hand Hygiene. The Clinical Competency Validation Hand Hygiene forms dated 2/2024 and 5/2024 for CNA #1, states met under all critical elements. 2. Wet hands with warm water. 7. Pat hands dry with a clean, dry paper towel. 8. Use clean, dry paper towel to turn off water. Review of the facility's policy titled Handwashing/Hand Hygiene revealed under Policy Interpretation and Implementation, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Under Procedure, under Washing Hands, 3. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. NJAC 8:39-19.4 (a) (1)

Based on observation, interview, and record review for two of three units (Rehabilitation unit and Secure unit) and five residents (Resident (R) 17, R196, R125, R2, R18) of 28 sampled residents revealed the food served was bland and residents did not receive salt, pepper, or Mrs. Dash to season their food after being served. Findings include: Review of R17's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/23 revealed R17 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R17 was cognitively intact. During the initial tour of the facility on 02/05/24 at 11:39 AM, R17 stated, The food doesn't have any taste, no spices in it at all. During an interview on 02/05/24 at 11:57 AM, R196 stated that the food was salty, especially the gravy. Review of R125's admission MDS with an ARD of 12/11/23 revealed a BIMS score of 13 of 15 which indicated that R125's cognition was intact. During an interview on 02/05/24 at 12:08 PM, R125's family member (F) 1 stated that the facility used to put salt, pepper packets, and butter on the resident's trays but did not do that anymore. F1 stated that the mashed potatoes tasted bland. Observation and interview on 02/05/24 at 12:14 PM revealed the first-floor lunch tray cart had no salt or pepper packets on the residents' trays. Certified Nurse Aide (CNA) 1 who was observed delivering lunch trays to residents on the first floor, confirmed that there were no salt or pepper packets on residents' trays. Review of R2's admission MDS with an ARD of 01/12/24 revealed a BIMS score of 15 of 15 which indicated that R2's cognition was intact. During an observation and interview on 02/05/24 at 12:25 PM, R2 was observed eating the soup on her lunch tray. R2 stated that the soup tasted warm not hot. She stated that the mashed potatoes tasted bland. During an interview on 02/05/24 at 12:25 PM, R18 stated that the facility food was terrible. She said that the dietary department cooked the meat, usually chicken or turkey, until it was dry. R18 said that the kitchen served the same vegetables on a regular basis, usually peas and carrots. She said that sometimes they would serve carrots that were almost raw, and inedible for her. R18 stated that the kitchen often did not cook what was posted on the menu. She said that sometimes the kitchen says that the meal was not cooked according to the menu because the delivery truck had not delivered the correct products. She stated that the kitchen often served items that local people did not like, not regular meals. During an observation, alongside the Dietary Manager (DM), the Regional Food Service Director (RFSD), and the Administrator on 02/07/24 at 12:05 PM, no salt or pepper packets were placed on trays during tray line lunch service. The packets were available on the tray line in the same caddy as the ketchup. During an interview at 12:10 PM, the Administrator stated the previous dietitian did not want the seasoning packets on the trays. During an observation on 02/07/24 at 12:41 PM, a test tray was evaluated for palatability for the rehabilitation (rehab) unit. The test tray was the last tray delivered to the rehab unit. The meal consisted of meatballs, brown gravy, green beans, and chicken vegetable soup. The soup was homemade and well flavored, the meatballs were hot but had no flavor. The brown gravy was bland as well. The tray did not include salt and pepper. During an observation on 02/07/24 at 12:58 PM, a second test tray was evaluated for palatability on the secure unit. The meal was an alternate meal on the menu. Lunch alternate included veal parmesan with pasta sauce and cheese, and mixed vegetables that included green beans, zucchini, and carrots. The veal was hot but had no flavor, the red sauce was not seasoned. The vegetables had no flavor and were overcooked. The tray did not include salt and pepper. During an interview on 02/08/24 at 9:30 AM, the cook revealed he followed the menu as it was written. When asked if he seasoned the pasta sauce the day before, he stated he had seasoned the first pan of sauce, however more residents ordered the alternate than normal. He stated he opened a can of marinara sauce and did not have time to season it before lunch. Review of the recipes for Swedish Meatballs revealed the cook should have added mushrooms and onions to the meal. The recipe for the meatballs indicated they were to be home made and the facility used pre-made meatballs. During an interview on 02/08/24 at 9:45 AM, the RFSD revealed he was not aware the red sauce had not been seasoned. 28306 26446 09262 NJAC 8:39-17.4(a)2,(e)

Based on observation, record review, interviews, and facility policy review, the facility failed to follow infection control procedures during a wound cleaning process, while delivering a meal tray to a resident in droplet isolation, and during room cleanings for residents in C-diff isolation for four of seven residents (Resident (R)86, R345, R134, and R194) reviewed for infection control standards of 28 sampled residents. Findings include: 1. Review of R86's undated Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R86 was readmitted to the facility on [DATE] with diagnoses of hypertension and peripheral vascular disease. Review of R86's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/23 revealed R86 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R86 was cognitively intact. During an observation of a dressing change to R86's sacral pressure ulcer on 02/08/24 at 10:59 AM, Licensed Practical Nurse (LPN) 1 removed the old dressing and discarded. The nurse removed her gloves and washed her hands. LPN1 donned clean gloves and cleaned the wound as ordered. Then the nurse patted the wound dry using one corner of a clean 4x4 and then using the same 4x4, the nurse turned the 4x4 to a corner that was not used and patted the wound dry again. LPN1 applied collagen powder, then applied calcium alginate, and covered the wound with an adhesive dressing. LPN1 did not change her gloves after cleaning the wound nor prior to redressing the wound with a new dressing. During an interview on 02/08/24 at 3:15 PM, LPN1 stated, I forgot to change my gloves before I put the dressing on again. During an interview on 02/08/24 at 4:17 PM, the Director of Nursing (DON) confirmed the nurse should have changed her gloves after the nurse cleaned the wound and before the nurse applied the new dressing. 2. Review of R345's undated Admission Record located under the Profile tab in the EMR revealed R345 was admitted to the facility on [DATE] with diagnoses of human immunodeficiency disease, liver cell carcinoma, and cerebral infarction. Review of the [Name] Nursing Comprehensive Assessment, dated 01/31/24, revealed R345 was oriented to person, place, and situation. The admission MDS had not been completed due to new admission on 01/31/24. During an observation on 02/06/24 at 12:30 PM, Certified Nursing Assistant (CNA) 1 donned personal protective equipment (PPE) before he went into R345's room. R345 was in droplet precautions. CNA proceeded to walk into the resident's room for a few minutes and then returned to the hallway with PPE still on and obtained the lunch tray for R345. CNA1 took the lunch tray into R345's room. CNA1 removed PPE prior to coming back into the hallway but was not observed to wash his hands prior to leaving the room. During an interview on 02/06/24 at 2:51 PM, CNA1 stated, I didn't realize I didn't wash my hands, but you are right I should have done this before I came out of the room. During an interview on 02/08/24 at 4:17 PM, the DON confirmed the CNA should have washed his hands after he removed his PPE and before coming out of the resident's room. 3. Observation on 02/05/24 at 3:43 PM revealed contact precautions signs posted on the outside of R134 and R194's bedroom doors. During an interview on 02/05/24 at 10:59 AM, Registered Nurse (RN) 1 stated that both R134 and R194 were in contact isolation due to having Clostridioides difficile (C-diff) (a bacterium known for causing serious diarrheal infections). RN1 stated that R134 was receiving vancomycin (an antibiotic medication used to treat a number of bacterial infections. Vancomycin was also taken orally as a treatment for severe C-diff colitis) oral tablet, and her last dose of the antibiotic would have been 02/11/24. RN1 stated that R194 had already completed the antibiotic to treat the C-diff. During an interview on 02/06/24 at 10:06 AM, in the presence of the Housekeeping Director (HD) and Housekeeper (HSK), who was observed sweeping and mopping floors of residents' rooms on the first floor, stated that when she mopped R134 and R194's bedroom and bathroom floors, she would use the same mop water and mop that she was using on every other resident's floors. During an interview on 02/06/24 at 10:06 AM, the HD confirmed that R134 and R194 were in isolation for C-diff and that the housekeeper would have used the same mop water and mop that the housekeeper used on other residents' floors. The HD stated that the product the housekeeper put in the mop water was called Pomona (cleaning chemical). On 02/06/24 at 10:30 AM, the HD provided the Pomona Material Safety Data Sheet (MSDS) which revealed that Pomona did not kill the C-diff spores. The HD stated that he spoke to the facility's Infection Preventionist (IP) and was informed to use bleach in the mop water when mopping the floors in residents' rooms who had C-diff. During further interview with the HD, he stated that he didn't know until today that the product, Pomona, did not kill C-diff spores. The HD stated that for those two residents' rooms, the housekeeper would have to use different water with bleach in it at a 10:1 ratio, a different bucket, and a different mop. When asked how the housekeeper would measure the bleach to create a 10:1 ratio, the HD stated that he would have to get a measuring cup to measure the bleach and that he would have to instruct the housekeeper how to create a 10:1 ratio. During an interview on 02/06/24 at 11:16 AM, the IP stated after reviewing the facility's Infection Control Surveillance logs for January and February 2024, that R194 was admitted on [DATE]. The IP stated that R194's stool culture in the hospital, dated 01/24/24, indicated C-diff bacteria and R194 was placed in contact isolation when admitted to the facility on [DATE]. The IP stated that R194 had completed the antibiotic. The IP stated that R134 was admitted from the hospital on 01/11/24 and that R134's stool culture, dated 01/31/24, showed C-diff bacteria. R124 was started on vancomycin 250 milligram (mg) every six hours on 02/02/24 and the antibiotic would continue until 02/12/24. The IP stated that he had instructed the HD before today, that when a resident was in contact isolation and had C-diff, housekeeping must use bleach in the mop water and to use a clean bucket and mop for these rooms. Review of the undated facility's policy titled, Cleaning of Patient Rooms identified with Clostridioides difficile indicated, Before cleaning .The Sodium Hypochlorite (commonly known in a dilute solution as bleach) disinfectant will be prepared daily .cleaning will be performed using a 1/10 dilution of Sodium Hypochlorite (Bleach) .13. Mop the floor. 14. Mop the restroom floor .Follow these rules, change mop water and mop after every isolation room . 09262 NJAC 8:39-19.4(a) (m) (n)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's baseline care plan contained the care and services required for two of two residents (Resident (R) 125 and R134) of 28 sampled residents, required upon admission to the facility. In addition, the facility failed to provide the summary of care to the resident and representative at the care plan meeting that was conducted after the admission Minimum Data Set (MDS) was completed. Findings include: 1. Review of R125's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed R125 was admitted on [DATE]. During an observation and interview on 02/05/24 at 12:06 PM, R125 received oxygen through a nasal cannula. R125 stated that he didn't use oxygen at home but started using oxygen at the hospital and since being admitted to the facility. During an interview on 02/06/24 at 3:06 PM, Social Worker (SW) Long Term Care (LTC) printed R125's Baseline care plan and R125's admission MDS with an Assessment Reference Date (ARD) of 12/11/23 which revealed a Brief Interview for Mental Status (BIMS) score of 13 of 15 which indicated that R125's cognition was intact. Review of R125's Baseline care plan section 3. Health Conditions, provided by the facility and dated 12/08/23, did not address R125's use of oxygen. SWLTC confirmed that the baseline care plan did not address R125's use of oxygen. During the interview on 02/06/24 at 3:06 PM, SWLTC stated that the care plan meeting was held on 12/22/23 and that R125's wife attended the meeting. Review of R125's Baseline care plan summary section 5. Summary and signatures, provided by the facility and dated 12/08/23, revealed B. Signature of Resident and Representative, 1. Resident signature and date indicated Reviewed and copy provided and 2. Representative signature and date indicated, Reviewed and copy provided. The document did not contain the signatures of either the resident or the representative. During an interview on 02/07/24 at 12:47 PM, R125's family member (F) 1 stated that she remembered the meeting but was not given a summary of his care or what they would be doing. F1 stated that if they had given her a document, she would have read it. She stated that they just talked with R125 and her. During an interview on 02/07/24 at 2:34 PM, SW Acute provided a SW note, dated 02/07/24, which indicated that F1 was provided copies of R125's care plan. SW Acute confirmed that the SW note was not written until today and that the wife was not given the care plan until today. 2. Review of R134's Face Sheet in the Profile tab of the EMR revealed that R134 was admitted on [DATE]. Review of R134's admission MDS with an ARD of 01/18/24 revealed a BIMS score of 12 of 15 which indicated that R2's cognition was moderately impaired. During an interview on 02/06/24 at 3:25 PM, SWLTC printed R134's Baseline care plan, which indicated R124's use of oxygen and contact isolation due to Clostridioides difficile (C-diff) (a bacterium that causes an infection of the colon. Symptoms include) were not indicated on the baseline care plan. The SWLTC confirmed that the baseline care plan sections A through I were blank and did not contain any information about the care and services R134 required which included the use of oxygen, contact isolation, and that she was still experiencing diarrhea due to C-diff. Review of R134's Baseline care plan summary section 5. Summary and signatures provided by the facility, dated 01/18/24, revealed B. Signature of Resident and Representative, 1. Resident signature and date indicated Reviewed and copy provided and 2. Representative signature and date indicated, Reviewed and copy provided. The document did not contain the signatures of either the resident or the representative. Review of Care plan meeting attendance sheet, provided by the facility and dated 01/18/24, revealed that R134's daughter attended the meeting. There was no documentation in the SW notes that R134's daughter had received the summary of R134's care. During an interview on 02/07/24 at 9:51 AM, SW Acute was shown R134's Baseline care plan section three Health Conditions for categories A through I and confirmed these sections were blank. Review of the facility's policy titled, Care Plans-Baseline, dated 01/24, revealed A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .2. The Interdisciplinary Team will review the healthcare practitioner's orders .and implement a baseline care plan to meet the resident's immediate care needs .4. The resident and their representative will be provided a summary of the baseline care plan . NJAC 8:39-11.1 NJAC 8:39-11.2

Based on interview, record review and facility policy review, the facility failed to encourage and arrange transportation for two of two residents (Resident (R) 46 and R128) of 28 sampled residents to activities of their choosing. Findings include: 1. During an interview on 02/05/24 at 2:37 PM, R46 stated that he used to go to the second floor for activities, but he was told that they stopped first floor residents from mingling with second floor residents. R46 stated that he liked Bingo, and that he had not been able to go to Bingo on the second floor and that he missed that activity. Review of R46's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed R46 was admitted to the facility on [DATE]. Review of R46's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/24 under the MDS tab in the EMR revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R46's cognition was intact. Review of the admission MDS section for Preferences for Customary Routine and Activities revealed documentation that it was very important for R46 to listen to music he liked, keep up with the news, and do things with a group of people. Review of R46's Care Plan in the EMR under the Care Plan tab revealed a goal that R46 would attend/participate in activities of choice three-five times per week with interventions which included Veteran's events, engaging with activity staff, and assisting in activity office to complete tasks. During an interview on 02/05/24 at 4:30 PM, R46's comment about not being able to go to the second floor to attend Bingo was shared with the facility's Administrator, who stated that he would follow up with the Activities Director. 2. During an interview on 02/06/24 at 1:01 PM, R128's family member (F) 3 stated that R128 wanted to go to the hot dog party but staff did not come and get him. Review of R128's Face Sheet in the EMR under the Profile tab revealed R128 was admitted to the facility on [DATE]. Review of R128's admission MDS with an ARD of 12/25/23 under the MDS tab in the EMR revealed a BIMS score of 15 out of 15 which indicated R128's cognition was intact. Review of the section for Preferences for Customary Routine and Activities revealed documentation that it was very important for [R128] to listen to music he likes, be around pets, keep up with the news, do things with a group of people, go outside to get fresh air and participate in religious services . Review of R128's Care Plan, dated 01/09/24 in the EMR under the Care Plan tab, revealed a goal for R128 was to maintain involvement in cognitive stimulation, social activities with interventions to include Establish and record [R128's] prior level of activity involvement and interests, modify daily schedule, treatment plan to accommodate activity participation as requested by [R128], Staff to introduce to peers .and encourage/facilitate interaction, such as poker, food programs, entertainment and sports . During an interview on 02/08/24 at 11:25 AM, the Activities Director (AD) stated that she had no documentation whether R46 and R128 were asked to attend an activity and refused. The AD stated that each day she delivered the Daily Chronical a one-page document that indicated the activities for the day, to each resident's room. She stated that the resident could review the activities for the day and if the resident wanted to attend an activity, the resident was to ask staff to take them to the activity. The AD stated that she had no documentation to show that R46 or R128 was asked if they wanted to attend an activity of their preference and whether they attended or refused to attend. Review of the facility's policy titled, Meaningful Resident Activities, dated 01/23, revealed To provide meaningful activities .Organization Plan for universal approach to Activities in a facility .All department will be responsible for assistance to and from scheduled activity programs . NJAC 8:39-7.3

Based one observation, interview, record review, and facility policy review, the facility failed to ensure that residents who could not perform their own Activities of Daily Living (ADLs) regarding bathing and grooming was provided by facility staff for two of two residents (Residents (R)193 and R194) of 28 sampled residents. Findings include: 1. Review of R193's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed R193 was admitted on [DATE]. No Minimum Data Set (MDS) information available. Observation and interview on 02/05/24 at 11:50 AM, revealed R193 had a full face of facial hair that was approximately half inch long and his fingernails were long with a dark substance underneath. Immediately at the time of this observation, Registered Nurse (RN) 1 entered the room and confirmed R193 should have been shaved and his nails trimmed. Review of R193's Care plan from the Care plan tab in the EMR with a date of 01/30/24, revealed a problem that R193 has an ADL self-care performance deficit with interventions .Bathing/Showering: Not attempted due to medical/safety concern. 2. Review of R194' Face Sheet in the EMR under the Profile tab revealed R194 was admitted on [DATE]. No MDS information available. Observation and interview on 02/06/24 at 10:44 AM, revealed R194 had an approximate half inch heavy facial hair. R194 stated at this time that he preferred to be shaved daily but he did not have a razor. Review of R194's Care plan from the Care plan tab in the EMR with a date of 02/01/24, revealed a problem that R194 had an ADL self-care performance deficit with interventions .Bathing/Showering: Not attempted due to medical/safety concerns. During an interview on 02/8/24 at 1:27 PM, Licensed Practical Nurse (LPN) 4 stated that the resident should have been shaved every day if he wanted to be shaved. LPN 4 confirmed that the resident had no showers since admission and only one bed bath. When LPN 4 reviewed R194's bathing documentation, she stated that she found that R194's bed bath had been marked as needed so LPN 4 changed R194's bath/shower so that it would occur two times per week. LPN4 stated this explained why R194 was not getting bed baths or showers. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, Documenting, dated 01/23, revealed Resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good .grooming ad person .hygiene .6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 8. Documentation will be completed in the Point of Care ADL documentation once care is completed each shift. NJAC 8:39-4.1(a)22

Based on interview, document review, and facility policy review, the facility failed to notify the State Survey Agency (SSA) within 24 hours of an allegation of abuse, in which 12 tablets for one of one Resident (R) 191's oxycodone narcotic medication was removed from the medication's bingo card and replaced with another pill of similar size but a different color. The facility failed to notify the SSA until two days and 10 hours after the allegation of misappropriation of resident's property was brought to the Director of Nursing (DON)'s attention. Findings include: Review of the facility's investigative document, provided by the facility, revealed that on the Atrium unit on 07/25/23 at 7:00 AM, two nurses, Licensed Practical Nurse (LPN) 1 and LPN2, reported immediately to the DON that 12 tablets from R191's oxycodone bingo card had been removed and replaced with 12 tablets of similar size but different color. The back of the card showed that for 12 bubbles, the bubble had been sliced open, the oxycodone removed and replaced with another pill, then taped to close the bubble. The oxycodone 7.5 mg bingo card had been received from the pharmacy on 07/20/23. Review of the facility's investigative file revealed a document titled Reportable Event Record/Report to the New Jersey (NJ) Department of Health Complaint unit, indicated that the event occurred on 07/25/23 at 7:00 AM and was reported on 07/27/23 at 5:30 PM. The document indicated 12 tablets of R191's oxycodone medication bingo card had bubbles that had been sliced open and the oxycodone medication had been removed, replaced with a pill of similar size but different color and the bubble taped over. The report was submitted to the NJ Complaint unit by the DON on 07/27/23 at 5:30 PM, which was two days and 10 hours after the DON had been notified by LPN1 and LPN2 of the missing oxycodone medication. During an interview on 02/07/24 at 11:04 AM, LPN1 stated that on 07/25/23 at 7:00 AM, she was the oncoming nurse and when she counted the narcotics with LPN2, she noticed that R191's bingo card looked different. She stated she turned the card over and saw that for 12 bubbles, there was tape over the bubble and that a pill of different color, but similar size had been replaced in the bubble. LPN1 stated that she and LPN2 reported the incident to DON immediately. During an interview on 02/07/24 at 11:14 AM, the Administrator confirmed that the reporting to the SSA was two days late. He stated that he thought the DON was reporting to the SSA and the DON thought the Administrator was reporting to the SSA. The Administrator stated that he was aware that the federal regulation and facility's policy indicated that it should have been submitted to the SSA within 24 hours. Review of the facility's policy titled, Controlled Substances, dated 10/23, revealed .9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. 10. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause an identify any responsibility parties . Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, dated 01/23, revealed Definitions. 1. Abuse .the deprivation by an individual .of goods or services that are necessary to attain or maintain physical .well-being . Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 10/23, revealed Policy Statement, Residents have the right to be free from abuse .misappropriation of resident property .Investigation Allegations: 1. The administrator .immediately reports his or her suspicion to the following .agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility .2. Immediately is defined as: a. within two hours of an allegation involving abuse .b. within 24 hours of an allegation that does not involved abuse . NJAC 8:39-9.4(f)

C#: NJ 0 Based on interviews, medical record review, and review of other pertinent facility documents on 7/8/2022, it was determined that the facility failed to administer medications according to the Physician's Order, failed to adhere to the acceptable standards of nursing practice, and failed to follow its policies titled Medication Shortages/Unavailable Medications and Charting and Documentation, for 1 of 3 residents reviewed (Resident#2). This deficient practice was evidenced by the following: Reference: 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 otherwise legally authorized Physician or Dentist. A review of the Electronic Medical Record (EMR) was as follows: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool dated 2/1/2022, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. The MDS also showed the resident needed minimal assistance with Activities of Daily Living (ADLs). Review of the Order Recap Report (ORR) for Resident #2 dated 01/01/2022 through 01/31/2022 included the following Physician's Order (PO's): [MEDICATION(S)] Nebulization Solution 2.5 MG ([NAME])/ 3 ML (Milliliter) 0.083%. 3 ML inhale orally via nebulizer four times a day related to Heart Failure dated 1/27/2022. Budesonide Suspension 0.5MG/ 2 ML. 2 ML inhale orally two times a day related to [CONDITION(S)] ([CONDITION(S)]) dated 1/26/2022. [MEDICATION(S)] Aerosol Solution 108 (90 Base) MCG (Microgram). 1 inhalation inhale orally every 6 hours related to [CONDITION(S)] dated 1/26/2022. Separate each puff of an inhaler for 1 minute to allow maximum absorption. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Nebulization Solution (2.5 MG/3 ML) 0.083% 3 ML inhale orally via nebulizer four times a day related to Heart Failure; on 1/27/2022 at 9:00 p.m., the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (9= sleeping). Budesonide Suspension 0.5 MG (Milligram)/2 ML (Milliliter) 2 ML inhale orally two times a day related to [CONDITION(S)]; on 1/27/2022 at 9:00 a.m., the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (7=Other/See Nurses Notes). [MEDICATION(S)] Aerosol Solution 108 (90 Base) MCG (Microgram) 1 inhalation inhale orally every 6 hours related to [CONDITION(S)], on 1/27/2022 at 12:00 p.m., the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (7=Other/See Nurses Notes). A review of Resident #2's Progress Notes (PNs) dated 1/27/2022 at 8:30 a.m. and 11:55 a.m. revealed the pharmacy did not deliver the medications. Further review of Resident #2's PNs showed no documentation that the resident's Physician was notified of the above-missed doses of medication. During the survey, the LPNs who failed to administer the above medications as ordered by the Physician were not available for an interview. During an interview on 7/8/2022 at 12:02 p.m., the Registered Nurse (RN) working in the Subacute Unit stated that when a medication is unavailable, the nurse usually checks the Pyxis (an automated medication dispensing system). If the medication is not in the Pyxis, the Physician is notified of the unavailable medication. The RN further stated the Physician would then give a substitute medication order or a hold order for the unavailable medication, and the new order is faxed to the pharmacy. The RN also stated the pharmacy is notified (by) via a phone call of the new order, and an estimated delivery time is obtained. All of this information should be documented in the PNs by the nurse. During an interview on 7/8/2022 at 12:31 p.m., the Surveyor asked the Director of Nursing (DON) the procedure when the pharmacy does not deliver medications for newly admitted residents. The DON stated the nurses are trained to check the Pyxis for unavailable medications. If the medications are unavailable, the nurses will call the pharmacy first to see if the delivery was in route then notify the Medical Doctor (Physician). The DON further stated the nebulizer treatments are common medications kept in the Pyxis. She explained that if a specific medication is unavailable in the Pyxis, the nurse is expected to notify the Physician for a hold order or for a substitute medication order for the unavailable medication. The DON stated the nurse should document all this information in the PNs. During an interview on 7/8/2022 at 2:48 p.m., the Surveyor asked the Attending Physician what should be done when a medication is unavailable. The Physician explained that usually, if a medication was not administered, the nurse is expected to call the Physician and notify him. The Physician further stated nebulizer treatments are common medications and are usually in the Pyxis, and he was not sure why it was not administered as ordered. The Physician explained that if a medication is unavailable, he will usually give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician stated, We make adjustments to make it work for the resident. If I have to call the pharmacy for a STAT delivery, I will do that. A review of the facility policy dated April 2018 titled Medication Shortages/Unavailable Medications policy revealed: When medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending Physician and the pharmacy provider. Under procedure: C: If a medication shortage is noted after pharmacy hours: 2: If the order medication is unavailable in the emergency stock supply, a licensed nurse calls the pharmacy's emergency answering service and requests to speak with the registered pharmacist on call to determine a plan of action which may include: a. Emergency/Stat delivery. A review of the facility policy updated 1/2022 titled Charting and Documentation under policy Interpretation and Implementation: 7. Documentation of procedures and treatments will include care-specific details, including Notification of family, Physician, or other staff if indicated. N.J.A.C:8:39-27.1(a)

C#: NJ 0 Based on interviews, medical record reviews, and review of other pertinent facility documents on 7/8/2022, it was determined that the facility failed to notify the resident's Physician of medications that were not administered and failed to follow its policy titled Physician/Family Notification This deficient practice was identified for 1 of 3 residents reviewed (Resident # 2) and was evidenced by the following: A review of the Electronic Medical Record (EMR) was as follows: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool dated 2/1/2022, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. The MDS also showed the resident needed minimal assistance with Activities of Daily Living (ADLs). Review of the Order Recap Report (ORR) for Resident #2 dated 1/1/2022 through 1/31/2022 included the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Nebulization Solution 2.5 MG ([NAME])/3 ML (Milliliter) 0.083%. 3 ML inhale orally via nebulizer four times a day related to Heart Failure dated 1/27/2022. Budesonide Suspension 0.5 MG/ 2 ML. 2 ML inhale orally two times a day related to [CONDITION(S)] ([CONDITION(S)]) dated 1/26/2022. [MEDICATION(S)] Aerosol Solution 108 (90 Base) MCG (Microgram). 1 inhalation inhale orally every 6 hours related to [CONDITION(S)] dated 1/26/2022. Separate each puff of an inhaler for 1 minute to allow maximum absorption. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Nebulization Solution 2.5 MG/ 3 ML 0.083%. 3 ML inhale orally via nebulizer four times a day related to Heart Failure; on 1/27/2022 at 9:00 p.m., the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (9= sleeping). Budesonide Suspension 0.5 MG/ 2 ML. 2 ML inhale orally two times a day related to [CONDITION(S)]; on 1/27/2022 at 9:00 a.m., the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (7=Other/See Nurses Notes). [MEDICATION(S)] Aerosol Solution 108 (90 Base) MCG. 1 inhalation inhale orally every 6 hours related to [CONDITION(S)], on 1/27/2022 at 12:00 p.m., the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (7=Other/See Nurses Notes). A review of Resident #2's Progress Notes (PNs) dated 1/27/2022 at 8:30 a.m. and 11:55 a.m. revealed that the pharmacy did not deliver the medications. Further review of Resident #2's PNs showed no documentation that the resident's Physician was notified of the above-missed doses of medications. During the survey, the LPNs who failed to administer the above medications as ordered by the Physician were not available for an interview. During an interview on 7/5/2022 at 12:02 p.m., the Registered Nurse (RN) working in the Subacute Unit stated to the Surveyor that if a medication is unavailable or not administered, the Physician should be made aware, and this should be documented in the PNs. During an interview on 7/5/2022 at 12:31 p.m., the Director of Nursing (DON) stated to the Surveyor that if a medication is unavailable or not administered, the Physician should be made aware, and this should be documented in the PNs. During an interview on 7/8/2022 at 2:48 p.m., the Physician stated to the Surveyor that if a medication is unavailable or is not administered, the nurse is expected to notify the Physician, and it should be documented in the PNs. The Physician further stated that he was not notified of the resident not receiving his/her medications. A review of the facility's undated policy and procedure titled Physician/Family Notification policy revealed: The resident, family, significant other, legal representative, responsible party, and or Physician shall be notified of the following: 3. In the event that the president's plan of care, treatment or medications are significantly altered. N.J.A.C:8:39-13.1.1(c)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least every thirty days for the first ninety days for new admissions or every sixty days after. This deficient practice was identified for 4 of 6 residents (Resident #3, #42, #49, and #66) during the Resident Council group meeting and evidenced by the following: On 11/8/21 at 10:01 AM, the surveyor conducted a resident group meeting with six residents who were alert and oriented and selected by the facility to attend the group meeting. Five of the six residents complained to the surveyor that they do not see their primary care physician (MD) or nurse practitioner (NP) regularly. Resident #42 stated that since admission, he/she has not seen their MD. On 11/8/21 at 11:03 AM, the Director of Nursing (DON) informed the surveyor that all MD and NP were conducting in-person visits for all residents at this time, unless the resident had an emergency, then a video visit would be conducted. The DON stated that MD and NP visits were conducted on a monthly basis and documented in the electronic medical record (EMR). At this time, the surveyor requested all MD and NP visits for the past six months for all six residents (Resident #3, #42, #43, #49, #66, and #75) On 11/8/21 at 11:59 AM, the DON provided the surveyor with the requested medical records. At this time, the DON stated that all the residents were seen by their MD or NP but confirmed that all the residents were not seen monthly as they should by their MD or NP. The surveyor reviewed the medical records for the six residents above which revealed the following: 1. A review of Resident #3's Admission Record, reflected that the resident was admitted to the facility in April of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly Minimum Data Set (MDS; an assessment tool) dated 10/25/21, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated a fully intact cognition. A review of the resident's physician visits provided by the facility, revealed that the resident had the following physician visits in the past six months: 5/12/21 podiatrist consultation, 7/14/21 podiatrist consultation, 8/10/21 MD visit, 9/8/21 MD visit, 9/23/21 podiatrist consultation, 9/28/21 NP visit, 10/13/21 MD visit. On 11/9/21 at 10:54 AM, the surveyor interviewed the Medical Director via telephone who stated that all long term care residents were seen monthly by either the MD or the NP. The Medical Director stated that the MD and the NP could alternate visits, but the NP could not have consecutive monthly visits without the MD visiting. On 11/10/21 at 9:34 AM, the DON in the presence of the Licensed Nursing Home Administrator, Assistant Director of Nursing (ADON) and survey team stated that Resident #3's MD was switched recently to the Medical Director. At this time, the surveyor requested all Physician Visits for the resident for the year of 2021. On 11/10/21 at 10:37 AM, the surveyor interviewed Resident #3 who stated that he/she recently switched MD since their previous MD retired. The resident stated that he/she within the past few months has seen the MD, but throughout the year has only seen specialty physicians such as a cardiologist (heart doctor), urologist (urinary doctor), and ophthalmologist (eye doctor). The resident stated that he/she has had no medical changes this year which would have required a MD or NP visit. On 11/20/21 at 10:55 AM, the DON confirmed that the resident was seen by specialty physicians throughout the year but was not seen regularly by their MD or NP. The DON confirmed that the 8/10/21 MD visit was the first well visit the resident received for 2021. 2. A review of Resident #42's Admission Record reflected that the resident was admitted to the facility in August of 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15 which reflected a fully intact cognition. A review of the EMR reflected a Health and Physical note dated 9/2/21 signed by the NP. A further review of the EMR reflected NP notes dated 9/12/21, 101/10/21, and 11/3/21. There was no documentation from the resident's MD. On 11/8/21 at 12:10 PM, the surveyor interviewed the resident's MD (MD #1) via telephone who stated that the NP (NP #1) was currently at the facility and that NP #1 discussed all the residents with her via telephone or video conference. MD #1 confirmed at this time, she has not been documenting in any of her residents' EMR, but NP #1 included in her notes that she reviewed with the MD. MD #1 acknowledged that she has not been at the facility and cannot recall the last time she was there because of personal issues, but she planned on returning to the facility. On 11/9/21 at 10:54 AM, the surveyor interviewed the Medical Director via telephone who stated that all new admissions should be seen first by the MD for their health and physical and then monthly by either the MD or the NP, with alternating NP visits allowed. On 11/10/21 at 9:34 AM, the DON in the presence of the LNHA, ADON, and survey team confirmed that the initial visit should be conducted by the MD and then monthly by the MD or NP. The DON stated that the NP could visit in between MD visits. The DON confirmed that MD #1 had spoken with NP #1 after each visit with Resident #42, but MD #1 was not physically here. The DON stated that after surveyor inquiry, MD #1 visited the facility. 3. A review of Resident #49's Admission Record reflected that the resident was admitted to the facility in June 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 15 out of 15, which indicated a fully intact cognition. A review of the resident's EMR revealed the following MD visits in the past six months: 5/26/21 and 8/18/21. The were no additional NP visits in the past six months. There was no required sixty-day visit for July 2021 or October 2021. On 11/10/21 at 9:34 AM, the DON in the presence of the LNHA, ADON, and survey team confirmed that the resident was seen by the MD after surveyor inquiry. 4. A review of Resident #66's Admission Record reflected that the resident was admitted to the facility in September 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 15 out of 15, which indicated a fully intact cognition. A review of the EMR reflected that the resident was seen by the MD in the past six months on 5/12/21 and 10/13/21. The EMR further revealed that the resident was seen by the NP in the past six months on the following dates: 6/28/21, 6/29/21, 6/30/21, 7/20/21, 7/28/21, 7/29/21, 7/31/21, 8/2/21, 8/4/21, 8/10/21, 8/11/21, 8/14/21, 8/18/21, 8/21/21, 8/23/21, 9/23/21, 9/28/21, 10/12/21, and 11/1/21. There was no evidence that the MD alternated the every sixty-day visit with the NP. On 11/10/21 at 9:34 AM, the DON in the presence of the LNHA, ADON, and survey team confirmed that the resident was seen by the MD after surveyor inquiry. A review of the facility's Physician Services policy dated updated 10/2019, included that the physician will perform pertinent, timely medical assessments; . visit resident at appropriate intervals; and ensure adequate alternative coverage. The policy also included that physician visits, frequency of visits, emergency care of residents, ects, are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. NJAC 8:39-23.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the reconciliation and notification of the physician for the clarification of an enteral feeding order in accordance with professional standards of nursing practice. This deficient practice was identified for 1 of 24 resident reviewed for professional standards of nursing practice (Resident #359). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: On 11/3/21 at 10:47 AM, during the initial tour, the surveyor observed Resident #359 lying in bed resting. The surveyor was unable to interview the resident as he/she was not interviewable. The surveyor reviewed the medical record for Resident #359. A review of the Admission Record face sheet (an admission summary) included that the resident was admitted to the facility in November 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's individualized care plan created 11/2/21, included that the resident required enteral feeding (delivers nourishment through a tube directly into the stomach) of [MEDICATION(S)] 1.5 at 120 milliliters (ml) (therapeutic nutrition that provides complete, balanced nutrition) four (4) times daily to be given only if oral (by mouth) intake was less than 50 percent of meals related to poor oral intake. In addition, the resident had an alteration in gastrointestinal status related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the November 2021 Medication Administration Record (MAR) for Resident #359 reflected a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if oral intake was greater than or equal to 50 percent; the order was discontinued on 11/3/21. The new PO started on 11/3/21, for the enteral feeding four times a day related to gastrostomy. Hold enteral feed [MEDICATION(S)] 1.5 cal bolus if oral intake was greater than or equal to 50 percent. On 11/5/21 at 10:22 AM, the surveyor interviewed the Registered Nurse (RN). The RN stated Resident #359 had an enteral feeding only if he/she did not eat their meal. She confirmed that the resident had received a bolus (administration of a certain amount of medication, drug, or other compound within a specific time) feeding during her shift. On 11/8/21 at 9:02 AM, the Licensed Practical Nurse (LPN) stated Resident #359 did not eat his/her breakfast and therefore would receive [MEDICATION(S)] 1.5 cal that morning. On 11/8/21 at 9:21 AM, the LPN went into the electronic medical record (EMR) to review the PO. The LPN verified that the enteral feeding of [MEDICATION(S)] 1.5 cal for Resident #359 and confirmed that the resident did not eat breakfast and would be given the bolus feeding. The LPN stated the resident does take his/her medications by mouth and the enteral feeding was a supplement for when the resident does not eat. The LPN further stated she was going to be administering a 60 ml flush before and a 60 ml flush after the bolus feed. On 11/8/21 at 9:23 AM, the surveyor observed the LPN prepare for the administration of the bolus feed. The LPN performed hand hygiene with an alcohol-based hand rub (ABHR), applied a pair of gloves and disinfected her stethoscope. She removed her gloves and applied ABHR. The LPN took out a new syringe and dated the package. The LPN then proceeded into the resident's room. On 11/8/21 at 9:29 AM, the LPN measured the 60 ml flush before the feeding and the 60 ml flush for after the feeding. The surveyor asked the LPN the total amount to be given. The LPN went back to the EMR because she stated she was not sure of the amount that should be given. The LPN reviewed the PO, and the LPN stated the PO was not clear on the total amount to be given and she needed to get clarification from the physician. On 11/8/21 at 9:34 AM, the LPN discarded the opened [MEDICATION(S)] 1.5 cal (355 cal/ eight (8) fluid ounces (fl oz): eight (8) fl oz / 237 ml) container and the water for the flushes. She removed her gloves and used ABHR and proceeded to the nursing station. The LPN then paged the dietician but there was no answer. She then called the Assistant Director of Nursing (ADON) and informed her the order needed to be clarified. The LPN then called the physician's office and left a message. On 11/8/21 at 9:38 AM, the Registered Nurse/Unit Manager/Infection Preventionist (RN/UM/IP), informed the surveyor that the previous order of 120 ml bolus feed from 11/1/21 was discontinued. She further stated that the order needed clarification from the physician to see if the order stayed the same of 120 ml or increased to 240 ml. The RN/UM/IP put another call out to the physician to get clarification on the enteral feeding. On 11/8/21 at 9:46 AM, the RN/UM/IP informed the surveyor and the LPN that she spoke with the primary physician for clarification of the enteral feeding and the physician reinstated the 120 ml order. On 11/8/21 at 9:53 AM, the LPN administered the enteral feeding of [MEDICATION(S)] 1.5 cal 120 ml bolus. On 11/9/21 at 9:03 AM, the RN/UM/IP stated all nurses were responsible for the reconciliation of the PO, but it was the primary task for the night shift 11 PM - 7 AM. She stated the original order on 11/1/21 was to give the 120 ml and then they updated the PO on 11/3/21 to include both the amount of meal intake and bolus feeding but the staff forgot to include the 120 ml. The RN/UM/IP stated all nurses were aware of the 11/1/21 order of 120 ml and they continued to give the bolus feeding according to that order. The surveyor and the RN/UM/IP reviewed the electronic MAR and it reflected on 11/4/21, 11/5/21 and 11/6/21 during breakfast the nurse administered the [MEDICATION(S)] 1.5 cal bolus feed without getting clarification of the amount from the primary physician. She further stated that she clarified the order on 11/8/21 with the primary physician to include the 120 ml as the total amount for the bolus feeding. On 11/9/21 at 9:23 AM, the Director of Nursing (DON) stated the 11 PM - 7 AM shift nurses conducted the reconciliation of physician orders. The DON acknowledged she was not sure what happened with the order and why the 120 ml amount was not carried over when the order was updated on 11/3/21. She stated she always had the same nurses on the units, and they know their residents. She further stated that the nurses knew the original order from 11/1/21 was to give 120 ml. The DON acknowledged if a new nurse was on the unit and caring for Resident #359 the order needed to be clarified to include the total amount to be given. She confirmed that Resident #359 generally does not eat in the morning but does eat lunch and dinner which the staff documents accordingly. On 11/9/21 at 10:12 AM, the surveyor interviewed the RN. The RN stated she was caring for the resident on 11/3/21, 11/4/21 and 11/5/21 and had administered the [MEDICATION(S)] 1.5 cal 120 ml because the resident ate less than 50 percent of their meal. The RN further stated she was familiar with the resident and the original order was to give 120 ml. The RN acknowledged that she should have notified the primary physician to clarify the PO. In addition, she should have notified the dietician regarding the 120 ml was missing in the order when it was transferred over to show oral intake amount and bolus amount. On 11/10/21 at 9:48 AM, the DON stated in the presence of the Licensed Nursing Home Administrator and survey team that the RN/UM/IP changed the order on 11/8/21 because the total bolus feed of 120 ml was missed during the reconciliation of Resident #359 orders. The DON acknowledged the order should have been clarified prior and the staff failed to ensure the supplementary documentation to show the amount of the bolus feed of 120 ml was included in the updated PO. A review of the facility's unnamed and undated policy included, All verbal, phone and written orders will be reviewed by the 11 PM - 7 AM nurse in order to avoid potential medication discrepancy .11 PM - 7 AM nurse will document findings of chart check by initialing if there were no issues noted, if discrepancy noted and if attending medical doctor was notified of need to modify or order clarified. A review of the facility's Enteral Tube Feeding via Syringe (Bolus) policy updated 10/2019, included .Verify .physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Check the following: (g) rate of administration (ml/hour). NJAC 8:39-11.2(b), 29.2(b)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 11/5/21 at 11:17 AM, the surveyor conducted a follow-up kitchen visit with the Dietary Director (DD) and observed the cook taking lunch food temperatures at the steam table. The surveyor observed the white steam table attached cutting board was deeply pitted and discolored black and reddish. At this time, the DD stated that staff sanitize the cutting board prior to serving food. She was unable to respond when questioned if this cutting board should be used; when cutting boards should be replaced; or when the cutting boards were last replaced. The DD then showed the surveyor a small white cutting board that was pitted and discolored black. On 11/5/21 at 11:21 AM, the surveyor interviewed the Regional Dietary Director (RDD) who stated that cutting boards should be replaced when there were scratches or indentations because bacteria growth could occur or quarterly. The RDD confirmed that both white cutting boards should not be in use and needed to be replaced. At this time, the RDD showed the surveyors one large blue, one large yellow, one large red, and one large brown cutting boards that were in use. The cutting boards were all pitted and discolored. The RDD confirmed that these cutting boards should not be in use and needed to be replaced. On 11/10/21 at 10:10 AM, the Licensed Nursing Home Administrator in the presence of the Director of Nursing and survey team stated that the RDD confirmed that the facility was using cutting boards that needed to be replaced. A review of the facility's Cleaning Instructions Cutting Board policy dated April 2020, included that all cutting boards shall be replaced no later than every three months or when they become excessively worn or develop hard to clean grooves. NJAC 8:39-17.2(g)

Complaint Intake #NJ 1 Based on interviews and record reviews, it was determined that the facility failed to implement a resident-directed treatment consistent with physician orders, as evidenced by the facility's failure to ensure a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: 1. Resident #2 admitted to the facility on [DATE] for rehabilitation services after a hospital stay to treat congestive heart failure (CHF). On 01/06/2021, the resident discharged to home with hospice services. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 14 out of 15, which indicated the resident was cognitively intact. The resident required extensive assistance with all activities of daily living (ADLs) except for eating, which required limited assistance. A review of Resident #2's medical record indicated the resident admitted to the facility with bandages on both legs and bruises to the arms and abdomen. A review of medical records indicated the resident received [MEDICATION(S)], a blood thinner medication. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's progress note dated 12/15/2020 at 1:26 AM indicated Resident #2 had bandages on both legs and a sacral wound which had been entered into the consult book. A review of records revealed a wound consultation was not completed for Resident #2. On 07/16/2021 at 1:46 PM, Medical Doctor (MD) #6 stated that Resident #2 was admitted to the facility after receiving care for CHF and wounds at a local hospital. MD #6 stated that because medications were failing to control the resident's leg [CONDITION(S)], a special multi-layer wrap was applied to the resident's legs while in the hospital to squeeze [CONDITION(S)] back into the resident's body. MD #6 stated the resident discharged from the hospital to the facility with no orders regarding the leg wraps. MD #6 stated the leg wraps were not to be removed by nursing staff. MD #6 stated the wraps should have been managed by a wound specialist, and he had placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/16/2020 at 2:35 PM, the Administrator (ADM) stated the QAPI (Quality Assurance and Performance Improvement) process was initiated upon learning of the failure to manage Resident #2's leg wraps. On 07/16/2021 at 2:44 PM, the Director of Nursing (DON) stated that at the time Resident #2 was in the facility, the process was that a wound consult order would be entered into a wound binder. The DON stated the consultant would then refer to the wound binder to determine the residents that needed a wound consultation. The DON stated that in this case, the wound consultant overlooked Resident #2's name, and the resident was not seen by the wound consultant. The DON was unsure when the facility became aware of the oversight but stated an investigation was started upon learning of the oversight. The DON stated the facility also changed the wound consultant group they used. During the survey, two attempts were made to contact the hospice company and hospice nurse who cared for Resident #2 once they discharged to home; however, these attempts were unsuccessful. New Jersey Administrative Code § 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the care of a resident with a permanent pacemaker, in accordance with the care plan and nursing professional standards of clinical practice. This deficient practice was identified for 1 of 1 resident reviewed for pacemaker care (Resident #22) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey included, 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 a 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 included, 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 02/11/20 at 11:01 AM, during the initial tour of the facility, the surveyor observed Resident #22 seated in a wheelchair at the resident's bedside and was accompanied by his/her resident representative (RR). The RR stated that the resident was hospitalized in December 2019 and had a permanent pacemaker inserted (a surgically implanted device that sends electrical impulses to the heart muscle to maintain the heart rate and rhythm). The RR stated that he/she conducted the pacemaker checks (a way for an implanted pacemaker to communicate with a physician or clinic using a small monitor) on the resident on the 11th of each month in the resident's room. The RR showed the surveyor a device located on the resident's window sill. The RR stated the device was held to the resident's chest and the device communicated the resident's pacemaker function directly to the cardiologist. The surveyor reviewed the Admission Record (an admission summary) which indicated that Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate resident care, dated 11/13/19, revealed that the resident had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. A review of the resident's Care Plan (CP) revealed an entry dated, 08/15/19, and revised on 02/04/20. The entry detailed the resident had a pacemaker related to [CONDITION(S)] (irregular heart beat). Further review of the CP revealed the resident required pacemaker checks. There were no specifics regarding the pacemaker checks documented in the CP. On 02/13/20, the surveyor reviewed Resident #22's medical record (MR) in the presence of the Unit Manager (UM #2) who stated that the resident's pacemaker was monitored at the cardiology office and not at the facility. She further stated that she lost the phone number to the cardiology office but wanted to phone the office for copies of the pacemaker reading results. Further review of the MR revealed a consult from the cardiology office, dated 11/15/19, that specified the facility should call the office for results. The UM #2 stated she would follow-up as the RR scheduled all resident doctor's appointments and provided the resident with transportation to the appointments. On 02/18/20 at 9:04 AM, the surveyor interviewed Resident #22 who was seated in a wheelchair in the resident's room. A device was observed on the window sill and was plugged into a nearby electrical outlet. The device was stored inside a blue box that was labeled with the trade name of a cardiac device manufacturer. The resident stated that all the nurses were aware that he/she had the device and the RR provided all required care for the device which included phoning the doctor for the permanent pacemaker function test. On 02/18/20 at 10:35 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that Resident #22 didn't have a permanent pacemaker. LPN #1 further stated that the RR was very involved with the resident and took the resident to all appointments. On 02/19/20 at 10:52 AM, the surveyor interviewed UM #2 who phoned the cardiology office in the presence of the surveyor and obtained a permanent pacemaker result that was conducted on 02/11/20. The UM #2 stated that she wasn't aware that the resident had a device at the facility that would read the pacemaker function, and that she observed the device in the resident's room for the first time that morning. UM #2 further stated that she became aware of the device when the Director of Nursing (DON) informed her of it that day. She then stated that the RR was trained by the cardiology office to do the pacemaker function tests and that he/she would come to the facility to do the tests. At that time, UM #2 also stated that the pacemaker function tests were completed by the RR on the 11th of each month. UM #2 stated that the resident's permanent pacemaker was inserted on 07/08/2019. UM #2 provided the surveyor with a copy of the resident's Care Plan. The surveyor reviewed an entry that was initiated on 08/15/20 which specified Pacemaker Checks and the entry was revised on 12/23/19. UM #2 could not provide information regarding the pacemaker checks and prior to 02/18/20, there was no order for pacemaker checks. According to UM #2, normally, the process would have been to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . UM #2 stated that she just thought that the pacemaker checks were being done at the cardiology office during scheduled appointments and were managed by the RR. A review of Resident #22's Order Summary Report, dated 02/18/20 revealed pacemaker check at the cardiology center, the RR sets up the appointment. On 02/19/20 at 11:18 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) for a copy of Resident #22's discharge instructions from the hospital after the resident had the pacemaker inserted. The ADON stated that a readmission note, dated 07/19/20, did not mention the permanent pacemaker placement. The facility was unable to provide the surveyor with documented evidence for physician's orders for the pacemaker checks and care of the pacemaker. On 02/19/20 at 12:02 PM, the surveyor interviewed the RR who stated that he/she was the resident's Power of Attorney and that he/she maintained responsibility for assisting Resident #22 to set up the pacemaker function reader device around November 2019. The RR stated that he/she was trained at the cardiology office, which the resident visited every three months, and that the pacemaker checks were conducted by him/her at the facility on the 11th of each month. The RR stated the cardiology office provided him/her with a check list to do the pacemaker checks and he/she did not alert the facility that he/she was performing the pacemaker checks. On 02/19/20 at 1:53 PM, the surveyor interviewed UM #2 who stated that she spoke to the RR who stated that she did not have to worry about the pacemaker because she took care of it. UM #2 stated that she told the RR that the facility was responsible for the resident and the facility was required to remain informed about the resident's care. On 02/19/20 at 2:29 PM, the surveyor interviewed the DON who stated that the RR handled the pacemaker follow-up care and provided the resident's transportation. She further stated that there was no physician order in place for the RR to check the pacemaker function at the facility. The DON stated the facility has not inspected the pacemaker reader device for electrical safety as required. The Regional Nurse stated that the monthly pacemaker checks conducted by the representative at the facility were considered a diagnostic test. She further stated that the existing order for cardiology to check the permanent pacemaker at office visits was not appropriate for the care and assistance that the resident received from his/her representative at the facility with the pacemaker readings. She further explained that resident office visits were scheduled quarterly. The surveyor reviewed the facility policy, Care of a Resident with a Pacemaker, updated 10/2019, which revealed, under Monitoring, that the pacemaker battery will be monitored remotely through the telephone or an Internet connection. The resident's cardiologist will provide instructions on how and when to do this. The policy revealed, under Documentation, that for each resident with a pacemaker, the following would be documented in the medical record: 1. The name, address, and telephone number of the cardiologist; order for pacemaker checks; type of pacemaker; and date last check was done. 2. When the pacemaker was monitored by the physician, document the date and results of the pacemaker surveillance, including: how the resident's pacemaker was monitored (phone, office, Internet); type of heart rhythm; functioning of the leads; frequency of utilization; and battery life. NJAC 8:39-11.2 (a), (d)

Based on observation, interview, and record review, it was determined that the facility failed to: a.) notify the physician of an injury sustained by a resident, b.) obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was identified for Resident #27, 1 of 2 residents reviewed for pressure ulcers, and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Administrative Code, Title 13, Law and Public Safety, Chapter 37, New Jersey Board of Nursing, under 13:37-6.5 Non-Delegable Nursing Tasks, includes: A registered professional nurse shall no delegate the physical, psychological, and social assessment of the patient, which requires professional nursing judgment, intervention, referral, or modification of care. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, 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 02/11/20 at 9:31 AM, during the initial tour of the facility, the surveyor observed Resident #27 seated in a wheelchair next to the bedside inside the resident's room. The surveyor observed that the resident had a non-adherent (non-stick) dressing on the right wrist. The non-adherent dressing was dated 02/10/20 and a band-aid was noted on the resident's left wrist. At that time, the surveyor interviewed the resident who stated the injury occurred when he/she self-propelled the wheelchair passed the former roommates' bed and banged both wrists on his/her wheelchair which caused blood to squirt from the right wrist. During this observation, the surveyor observed a bed next to the entrance to the room that was placed laterally against the inside wall with an air mattress pump affixed to the foot of the bed, as was described by the resident. The resident stated that his/her former roommate's bed was not placed against the wall at the time of the injury and stated that the air mattress pump affixed to the foot of the bed made it difficult to pass by in his/her wheelchair. According to Resident #27's Admission Record (an admission summary), the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an Annual Minimum Data Set (MDS), an assessment tool used to facilitate resident care), dated 08/20/2019, revealed the resident had a Brief Interview for Mental Status Score of 15, which indicated that the resident was cognitively intact and was self-sufficient in wheelchair with locomotion on and off the unit with supervision of one person. Further review of the MDS revealed that the resident required extensive assistance of one staff member to transfer from a chair to a standing position and to walk within the room. On 02/12/20 at 12:08 PM, the surveyor interviewed Resident #27 who stated that on 02/11/20, the facility requested and obtained a written report from the resident that detailed how the resident's skin injuries occurred approximately two weeks prior. The surveyor observed a scabbed area on the resident's left wrist that was previously covered with a band-aid and a non-adherent dressing on the right wrist, dated 02/12/20. The surveyor reviewed a Progress Note (PN), dated 02/05/20 at 7:08 AM, which revealed that Licensed Practical Nurse (LPN #7) documented that Resident #27 had an opened purpura (a rash of purple spots on the skin caused by internal bleeding from small blood vessels) noted to the right lower arm and the resident stated that he/she didn't know how it happened as the resident stated when he/she awoke it was already there. LPN #7 initiated a wound treatment with triple antibiotic ointment (a combination of medications used as a first aid antibiotic to prevent infections in minor cuts, scrapes or [CONDITION(S)]), applied after the wound was cleansed with NSS (normal saline solution), then covered the area with a non-adherent dressing x 5 days. Further review of the PN revealed that there was no documented evidence that a Registered Nurse or the resident's Attending Physician or Nurse Practitioner was notified of the resident's injury. On 02/14/20 at 10:00 AM, the Assistant Director of Nursing (ADON) provided the surveyor with a narrative skin tear incident report, initiated by Unit Manager #1 and dated 02/05/20 at 6:30 AM with a revision date of 02/13/2020 at 6:38 PM, that pertained to Resident #27's injury. The nursing description portion of the skin tear report revealed that the 11-7 Certified Nursing Assistant (CNA) called the Unit Nurse (LPN #7) and reported that the resident's right lower arm was bleeding. The Unit Nurse (LPN #7) assessed the resident and it appeared to be an open purpura. The resident description portion of the skin tear report revealed that at the time of the incident, the resident was unable to recall what happened an upon investigation, the resident verbalized that he/she hit her arm on the resident's air mattress pump while trying to leave the room. The immediate action taken revealed that first aid was administered (site cleansed with NSS and a clean, dry dressing was applied) and the Medical Doctor (MD) and family were contacted. Treatment was initiated and the air mattress pump was moved. The agencies/people notified section revealed no notifications found. The document did not specify that triple antibiotic ointment was rendered during first aid treatment as detailed within the PN and that the physician and family were notified. The document further revealed that there was no documentation that a RN assessed the resident's wound. A review of the February 2020 Treatment Administration Record (TAR) reflected an entry, dated 02/05/20 at 6:34 AM for Triple Antibiotic Plus Ointment 1% (Neomy-Bacit-Polymyx-[MEDICATION(S)]) Apply to right lower arm topically one time a day for open purpura for 5 days. Cleanse open purpura to right lower arm with NSS, pat dry, apply triple antibiotic ointment then cover with non-adherent dressing x 5 days. On 2/19/20 at 10:14 AM, the surveyor interviewed the Director of Nursing (DON) who stated that an assessment was required to be completed by a Registered Nurse. She further stated if it was a small skin tear, she trusted her LPNs to do an assessment but if it was a big one, they were required to call. The DON stated that she expected LPN #7 to initiate the treatment first and then call the doctor since the triple antibiotic ointment was available over the counter. The DON further stated that she would have to check the facility protocol to see if it was appropriate to place a wound treatment order in the computer without first speaking with a physician and she was unable to furnish documented evidence that this was permissible. On 02/19/20 at 9:30 AM, the DON furnished the surveyor with a second handwritten Accident/Incident Report, dated 02/05/20 at 6:30 AM, that was completed by LPN #7. A review of the document revealed that LPN #7 did not document notification of Resident #27's attending physician or family representative of the resident's injury in the required fields on the report. Further review of the document indicated that LPN #7 applied triple antibiotic to the wound and covered the area with a dressing. On 02/19/20 at 9:57 AM, the surveyor interviewed LPN #7 in the presence of UM #1, DON, and survey team. LPN #7 stated that the CNA asked LPN #7 to check Resident #27's right arm because it was bleeding. LPN #7 checked the resident's arm and observed a skin tear on the resident's right wrist. LPN #7 stated he applied triple antibiotic ointment to Resident #27's right wrist without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He further stated that at least he was able to initiate the treatment. LPN #7 stated that he then placed an order into the computer system for Resident #27's wound treatment per house protocol without first notifying the physician or obtaining a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the surveyor on 02/19/20 at 10:03 AM, UM #1 stated that she obtained the 24-Hour Summary and there was a call out to the doctor. She further stated that the Advanced Practice Nurse was notified and believed that she came into the facility that day. UM #1 stated that she didn't document those interventions because she was very busy that day. The surveyor reviewed the 24-Hour Summary, dated 02/05/20 at 7:08 AM, which detailed that Resident #27 had an open purpura noted to the right lower arm. The resident didn't know how it happened and stated that it was already there when he/she woke up. Treatment initiated with triple antibiotic ointment post NSS cleans then cover with non-adherent dressing x 5 days. A second entry was noted on the 24-Hour Summary, dated 02/05/20 at 1:00 PM, which indicated that the open purpura on Resident #27's right hand continued with treatment and the dressing was clean and dry. On 02/19/20 at 3:24 PM, the surveyor interviewed the Regional Nurse (RN) who stated that a skin assessment form was not completed on the date of the injury as required. She further stated that a RN was responsible to assess a skin injury in accordance with professional standards of practice but that was not specified within the facility policy. The RN stated that a RN or LPN Supervisor could assess a skin injury assessment performed by an LPN but that was not done as LPN #7 failed to notify the house supervisor at the time of the resident's injury. A review of the facility's Medication and Treatment Orders policy, updated 10/19, revealed that orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. NJAC 8:39-11.2(b)

Based on observation, interview, and record review, it was determined that the facility nursing staff failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] This deficient practice occurred for 1 of 4 residents reviewed for respiratory care, Resident #291, and was evidenced by the following: During the initial tour of the subacute unit on 02/11/20 at 10:04 AM, the surveyor observed Resident #291 lying in bed, awake and alert. The resident wore a nasal cannula (oxygen tubing) that was connected to an oxygen concentrator (a medical device used for delivering oxygen) that was set at 4 liters per minute (L/min). Resident #291 stated that he/she used oxygen at home at 3 L/min. On 02/12/20 at 11:06 AM, the surveyor observed Resident #291 lying in bed, awake and alert. The resident wore a nasal cannula (oxygen tubing) that was connected to an oxygen concentrator that was set at 3 L/min. The resident stated that at home he/she used 3 L/min but could adjust to 4 L/min if needed. The resident stated he/she did not change the oxygen levels on the oxygen concentrator while at the facility. According to the Admission Record (an admission summary), Resident #291 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set (an assessment tool), dated 02/07/20, revealed Resident #291 was cognitively intact, needed the assistance of one person for mobility and received respiratory therapy. A review of progress notes, dated 01/31/20 through 02/14/20, revealed varied documentation of the oxygen levels that were administered to Resident #291 which included the following: On 01/31/20 at 14:55 (2:55 PM), a Registered Nurse (RN #1) documented the resident was administered oxygen via NC at 2 L/min. On 02/01/20 at 06:39 AM, a Licensed Practical Nurse (LPN #4) documented the resident was administered oxygen at 2 L/min. On 02/01/20 at 14:05 (2:05 PM), LPN #5 documented the resident was administered oxygen at 2 L/min. On 02/09/20 at 18:14 (6:14 PM), RN #2 documented the resident was administered oxygen at 2 L/min On 02/12/20 at 15:01 (3:01 PM), LPN #6 documented the resident was administered oxygen at 2 L/min. On 02/14/20 at 11:12 AM, LPN #1 documented the resident was discharged to home on continuous oxygen at 2.5 L/min. During an interview on 02/14/20 at 11:48 AM, LPN #1 stated that Resident #291 was discharged home on oxygen at 2 L/min. LPN #1 stated that residents on oxygen would have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At that time, in the presence of the surveyor, LPN #1 was unable to locate a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Order Summary Report, dated 02/16/20, failed to include a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the Director of Nursing (DON) on 02/18/20 at 2:15 PM, the DON stated when a resident was admitted on oxygen, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated there should have been a PO for Resident #291's oxygen because oxygen was considered a medication. During an interview on 02/20/20 at 8:30 AM, the Medical Director (MD) stated Resident #291 was dependent on oxygen and used oxygen at home. The MD stated the resident's hospital transfer sheet indicated that Resident #291 was on oxygen upon admission and the nurse must have skipped that order when the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Oxygen Administration policy, updated 10/2019, revealed under the preparation section, to verify that there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain appropriate infection control practices for hand hygiene and cleaning equipment during blood glucose testing and insulin administration. This deficient practice was identified for 1 of 4 nurses observed on 1 of 3 units during the medication pass for Resident #27, 1 of 1 resident reviewed for insulin administration and was evidenced by the following: On 02/14/20 at 11:16 AM, in the presence of License Practical Nurse (LPN #3), the surveyor prepared to inspect Medication Cart #1 on the Terrace Unit . The surveyor observed Resident #27 seated in a wheelchair in the doorway to the resident's room, adjacent to the medication cart. Resident #27 requested that LPN #3 check his/her blood sugar and administer the scheduled insulin at that time, as the resident planned to go to lunch. LPN #3 removed a blood glucose meter from a clear plastic bag located inside the top drawer of the medication cart, and placed the blood glucose meter on top of the medication cart. She did not clean the blood glucose meter at that time. She obtained glucose test strips, alcohol prep pads and some tissues and entered the resident's room. LPN #3 placed the tissues on top of the resident's roommate's dresser as a barrier between the top of the dresser and the diabetic testing supplies without first sanitizing the surface of the dresser. Without performing hand hygiene, LPN #3 applied gloves, cleansed Resident #27's right index finger with an alcohol pad, pricked the finger with a lancet, and placed a drop of the resident's blood onto the test strip, and then inserted the test strip into the blood glucose meter. LPN #3 reviewed the blood glucose result displayed on the glucose meter and then discarded the lancet and test strip into the sharps container (hard plastic container used to safely dispose of [MEDICATION NAME] needles and other disposable medical instruments) located on the side of the medication cart. The remainder of the supplies were discarded into the trash can located on the outside of the mediation cart. Without cleaning the blood glucose meter, LPN #3 placed it back into the clear plastic bag, that was located on top of the medication cart, and then placed it back inside the medication cart drawer. She then removed her gloves, disposed of them in the trash can. LPN #3 did not perform hand hygiene. Without performing hand hygiene, LPN #3 accessed a computer that was located on top of the medication cart. She then removed a vial of insulin and proceeded to withdraw the desired amount of insulin using an insulin syringe. LPN #3 then applied gloves and administered the insulin to Resident #27 in the right upper abdominal area. After discarding the used insulin syringe in the sharps container, LPN #3 then removed and disposed of her gloves. She utilized a hand wipe to cleanse her hands prior to charting the insulin administration into the computer. When interviewed at that time, LPN #3 stated that the blood glucose meter was cleaned after she utilized it last, and stated that was in the morning. She stated she was not required to clean it prior to each use. She further stated that she should have cleaned the blood glucose meter before she stored it away, and that was my mistake. LPN #3 then proceeded to do the following: applied gloves, removed the blood glucose meter from the plastic bag, obtained a sanitizer cloth, and wiped the blood glucose meter three times on the front, back and tip (point of platform or test strip insertion) of the blood glucose meter. She then placed the blood glucose meter back into the plastic bag immediately, and stated that the dry time for the blood glucose meter was 30 seconds. LPN #3 removed her gloves and cleansed her hands with hand sanitizer. As the interview continued, LPN #3 stated that she had washed her hands prior to the surveyor's arrival, and obtained the needed supplies, applied gloves and checked Resident #27's blood glucose. She stated that she should have washed her hands after she obtained the resident's blood sugar. LPN #3 stated that her hands were clean and that was why she didn't wash her hands, but instead used a wipe to perform hand hygiene after the insulin injection was administered as handwashing was only required if hands were visibly soiled. On 02/14/20 at 11:50 AM, the surveyor interviewed Unit Manager (UM #1) who stated that nursing was required to perform handwashing for 30 seconds, use hand sanitizer or hand wipes prior to gathering the supplies for insulin administration. UM #1 stated that the glucose meter should have been clean already when it was contained inside the plastic bag located inside the medication cart. She further stated that the glucose meter should be wiped with a sanitizer wipe and allowed to dry for one minute prior to use. UM #1 stated if supplies were placed on the bedside table the surface should have been cleaned prior to placing the supplies on top of the tissue utilized as a barrier. UM #1 also stated that hand hygiene was required with hand sanitizer or wipes, prior to applying gloves and after glove removal. UM #1 stated that the nurse was required to apply gloves and wipe down the glucose meter and allow it to dry. Gloves were then to be removed prior to using the computer. On 02/18/20 at 3:06 PM, the surveyor interviewed the Director of Nursing (DON) who stated that an in-service on blood glucose monitoring was provided to nursing staff approximately three weeks ago. She further stated that in order to disinfect the blood glucose meter, the staff were required to wipe the front and back of the meter with an approved sanitizer wipe. After the meter was wiped with the sanitizer, it should sit and dry for two minutes. On 02/19/20 at 3:08 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who served as the facility's infection preventionist. The ADON stated that nursing should dispose of both lancets and test strips inside the sharps containers located on the medication carts. She further stated that if nursing disposed of discarded lancets or test strips inside the trash cans located inside the resident's rooms, it could pose a risk of blood exposure to both confused residents and or unknowing staff members. The ADON stated that the facility always required that blood glucose test strips and lancets to be discarded into the sharps container. The ADON stated that handwashing was required before all procedures and after glove removal. The ADON stated that disinfectant wipes were used to clean the blood glucose meters and could not recall the drying time required before the blood glucose meter was placed in a plastic bag for storage. The surveyor reviewed the facility's Blood Glucose Sampling-Capillary (Finger Sticks) policy, revised 10/2019, which revealed to always ensure that blood glucose meters intended for reuse were cleaned and disinfected between resident uses and handle the lancet as a used needle. The procedure steps included the following: Wash hands. Don (apply) gloves. Place blood glucose monitoring device on clean field. Place a new lancet and disposable platform on the spring-loaded finger-stick device. Wipe the area to be lanced with an alcohol wipes (sic.). Obtain the blood sample, following the manufacturer's instruction for the device. Discard lancet and platform into the sharps container. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts and/or devices after each use. Remove gloves, and discard into receptacle. Wash hands. Replace blood glucose monitoring device in storage area after cleaning. Review of the facility's undated Cleaning and Disinfecting the Meter policy revealed to always ensure that blood glucose meters intended for reuse were cleaned and disinfected between resident uses. The Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures were followed. The policy included: Cleaning: Wear appropriate protective gear such as disposable gloves. Open the towelette container and pull out one towelette and close the lid. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using 1 towelette to clean blood and other body fluids. Dispose of the used towelette in a trash bin. Disinfecting: The meter should be cleaned prior to disinfection. Open the towelette container and pull out one towelette and close the lid. Wipe the entire surface of the meter three (3) times horizontally and 3 times vertically to remove blood-borne pathogens. Dispose of the used towelette in a trash bin. Allow exteriors to remain wet for the appropriate contact time and then wipe the meter using a dry cloth. Disinfectant Brand Name Super Sani-Cloth Germicidal Disposable Wipe 2 minutes. After disinfection, the user's gloves should be removed and thrown away. Wash hands before proceeding to the next patient. Review of the facility's Handwashing/Hand Hygiene Policy, updated 10/2019, revealed to wash hands with soap (antimicrobial or non-antimicrobial) and water when hands were visibly soiled. Use an alcohol based hand rub containing at least 62% alcohol; or soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents; before preparing or handling medications; after contact with a resident's intact skin; after contact with blood and body fluids; and after removing gloves. NJAC 8:39-19.4(a) (1) and 27.1(a)

COMPLAINT # NJ 6 Based on interviews, Medical Record (MR) review, and review of other pertinent facility documents on 8/9/2019 and 8/13/2019, it was determined that the Facility staff failed to develop a comprehensive care plan to address skin monitoring of the left lower leg (LLL) and implement interventions to prevent skin breakdown. This deficient practice occurred for 1 of 2 residents, (Resident #2). In addition, the Facility failed to follow their Policy titled Care Plans, Comprehensive Person-Centered for 1 of 2 residents (Resident #2) sampled for Care Plans. This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 12/10/2018, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating the Resident's cognition was moderately impaired. The MDS also indicated Resident #2 required extensive assistance with Activities of Daily Living (ADLs). Review of Resident #2's physician's orders [REDACTED]. Review of the facility document titled Braden Scale for Predicting Pressure Sore Risk dated 12/13/2018, revealed a score of 16/18, indicating that Resident #2 was At Risk for developing a pressure ulcer. Review of Resident #2's Care Plan (CP) with an initiation date of 12/17/2018 and a revised date of 12/30/2018, revealed the following: Focus Resident has an actual skin impairment to the left lower extremity and foot, multiple deep tissue damage to dorsal, and plantar foot. Under Interventions Apply skin prep to heels every shift. Follow facility protocols for treatment of [REDACTED]. Review of Resident #2's MR did not show documentation that skin assessments under the air cast were done. During an interview on 8/13/2019 at 12:30 p.m., the Director of Nursing (DON) stated she did not know why the Care Plan did not address Skin Issues related to the Air Cast. Review of the Facility's Policy titled Care Plans, Comprehensive Person-Centered with an adopted date of 11/2018, revealed the following: under Policy Statement; A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional need is developed and implemented for each resident. N.[NAME][NAME]C. 8:39-11.2(e)1

COMPLAINT #: NJ Based on interviews and review of the medical record and other facility documentation, it was determined that the facility failed to implement a safety intervention, to provide adequate supervision during ambulation to prevent falls using Contact Guard Assistance, for 1 of 7 sampled residents (Resident # 5). Resident #5 who had a history of [REDACTED]. The Physical Therapy (PT) Department conducted the PT screens after the falls, on 4/9, 5/19 and 5/22/15 and Resident #5 was determined to need contact guard assistance (CGA) by staff for ambulation and transfers which was not implemented by staff after any of the falls. Resident #5 subsequently had an unwitnessed fall on 6/11/2015 and sustained Left Femoral Neck Fracture which resulted in pain management, hospitalization and surgery. This deficient practice is evidenced by the following; Reference: http://physicaltherapy.about.com/od/Physical-Therapy-For-Seniors/a/Various-Levels-Of-Assistance-In-Physical-Therapy.htm : Contact Guard Assist: With contact guard assist, the physical therapist needs to merely have one or two hands on your body, but provides no other assistance to perform the functional task. The contact is made to help steady your body 1. According to the facility face sheet, Resident #5 was admitted to the facility in 3/2012 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 5/18/15, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe cognitive impairment and could walk in the room, corridor and on the unit with supervision-oversight encouragement or cueing with needed setup help only. In addition, the MDS revealed that balance during walking and turning around, was steady at all times and was not steady, but able to stabilize without staff assistance for a seated to standing position. The Care Assessments Administration (CAA), for the 5/18/2015 MDS, also indicated that Resident #5 was at risk for falls due to (d/t) poor safety awareness and ambulated on the unit independently; paced the hallways and when tired, starts to lean forward while ambulating. Resident #5 also misinterprets the different colored tiled flooring as objects and tries to pick them up increasing her risk for fall. Staff closely monitor (resident) and redirect (resident) to activities. A facility Care Plan (CP), dated 5/18/2015, showed Resident #5 was at risk for falls d/t cognitive impairment, poor safety awareness and pushing and pulling tables and carts. The CP revealed that Resident #5 walks aimlessly in hallway and room to room, removes socks and shoes and transfers without calling for staff assistance. Actual falls included but were not limited to; 4/7/15, 5/10/15, 5/21/15 and 6/11/15. Interventions included but were not limited to; involve in activities, maintain clutter free environment, ensure proper foot wear, low bed and refer to rehabilitation as needed (PRN) when indicated. There was no indication in the CP that PT screens had been completed on 4/9, 4/19 and 5/22/2015 or that contact guard by staff was recommended for ambulation and transfers. On 6/12/2015, the NJ Department of Health received a Facility Reportable Event Record (AAS-45) from the facility. An undated Incident Investigation Summary by the Director of Nursing (DON) revealed Resident #5 resided in the dementia unit, is awake, confused and displays behavioral symptoms and ambulates aimlessly in the unit hallways without assistance. At approximately 6:25 a.m. on 6/11/2015, the unit nurse administered medication to Resident #5. A CNA in one of the rooms said she heard a thud and came out of the room and saw Resident #5 lying on the floor. At approximately 6:30 a.m., Resident #5 was found on the floor in the hallway of the unit, able to move her right arm and leg but screamed when her left arm and leg were touched. The resident was wearing non skid socks and the unit was free of clutter and dry. Tylenol was given for pain and Resident #5 was transported to the hospital emergency room and was admitted with a [DIAGNOSES REDACTED]. The DON noted there was no abuse or neglect after review of the incident. The surveyor reviewed the MR and found Rehabilitation Referrals from the unit for PT screens for the 4/7, 5/10 and 5/21/15 falls, however, the results of the PT screens were not in the MR. The Unit Charge Registered Nurse (RN) also reviewed the MR at that time and could not locate them. The RN confirmed that the PT screens would have been reviewed and should be in the MR. During an interview with the surveyor on 7/16/2015 at approximately 1:30 p.m., the surveyor asked what level of assistance and supervision Resident #5 needed prior to the fall on 6/11/15 which resulted in a fracture. The 7-3 unit charge RN, 7-3 unit Licensed Practical Nurse (LPN) and a regularly assigned 7-3 certified nurses aide (CNA) for Resident #5 all stated that Resident #5 ambulated on the unit without any assistance from staff but the staff would observe her whereabouts. The staff confirmed that they were not aware that Resident #5 needed CGA for ambulation. During an interview with the surveyor on 7/16/2015 at 1:15 p.m., the Rehabilitation Manager brought the results of the PT screens, dated 4/9, 5/19 and 5/22/15 completed by the Physical Therapist which revealed that Resident #5 presented with flexed posture and anterior translation with ambulation. The resident was assessed with [REDACTED]. The 4/9, 5/19 and 5/22/15 PT screens all indicated that Resident #5 required CGA and constant verbal cues with all functional mobility to prevent further falls and maintain safety. During an interview with the surveyor at 1:45 p.m. on 7/16/15, the Physical Therapist who conducted the PT screens confirmed her findings and added that the usual routine for a PT screen can be that it is conducted with the resident and the staff at the same time or the Physical Therapist will speak with the staff after the PT screen is completed, a copy of the results are given to the unit nurse for the MR and staff education is documented on the PT screen. The Physical Therapist stated she spoke with Resident #5's unit staff after each of the PT screens and educated them, however, she was unable to remember who she spoke with. Review of the PT screens had no staff education documented. The surveyor asked the Physical Therapist what CGA meant and the Physical Therapist stated; physical hands on the resident while ambulating. Review of the Interdisciplinary Nursing Progress Notes (INPN), dated 4/7/2015 at 3:08 p.m. and 3:05 p.m. revealed that Resident #5, at 2:50 p.m., was observed in the dining room, grabbed a wooden item and threw it to the floor, stomped on it and lost her balance and fell on to her left side, landed on buttocks and picked herself up and sat on the couch. An assessment was done with no injury noted. A PT screen, dated 4/9/2015 and signed by the Physical Therapist, indicated Resident #5 was not appropriate for use of rolling walker (RW) or wheelchair (w/c) secondary to impaired safety awareness and agitation and needed CGA for ambulation and transfers to maintain safety and prevent future falls. Resident #5's CP was updated on 4/7/15 with an intervention to observe for signs and symptoms (s/s) of increased agitation. There was no further documentation in the CP related to (r/t) the results of the PT screen on 4/9/15 or that any assessment was done r/t Resident #5 needing CGA while ambulating. Further review of the INPN revealed that Resident #5 continued to ambulate without assistance from staff; 4/22/15 at 6:10 a.m.; .pacing unit.disrobing and trying to pick up all the tiles off the floor.difficult to redirect.; 4/23/15 at 1:51 p.m.; .observed walking briskly up and down the halls of the nursing unit.then went to her room and slammed the door shut.; 4/25/15 at 7:01 p.m.; .Patient continues self ambulating up and down the hallway. Going into other patients rooms and pulling down the covers, redirection is not effective.; 4/26/15 at 7:56 p.m.; .continues self ambulation up and down the hallway.; 4/27/15 at 6:09 a.m.; pacing hallways attempting to take rails off the walls and attempting to exit emergency door.easily redirected.; 4/28/15 at 6:30 a.m.; .pacing hallways.; 4/29/15 at 6:10 a.m.; .pacing in hallway back and forth to dining room.6 a.m. still pacing unit.; 5/8/15 at 1:07 p.m.; At approximately 8 a.m.writer was at the med (medication) cart preparing medications by the nursing office and the 2 CNAs (certified nurses aides) were in a room assisting another resident. Writer heard a loud bang and observed the resident walking from the pantry.and continued to walk down the hallway.; 5/9/15 at 9:05 p.m.; .pacing back and forth in the hallway. On 5/10/2015 at 10:01 a.m., the INPN revealed that at approximately 9:45 am, Licensed Practical Nurse (LPN # 2) was at the nurses station, heard a noise and stepped out of the office to find Resident #5 sitting on the floor next to the medication cart. Resident attempted to get back up on her own but LPN #2 encouraged resident to remain on floor. The resident was assessed with [REDACTED]. A PT screen, dated 5/19/2015 and signed by the Physical Therapist, indicated Resident #5 was not appropriate for PT secondary to inability to follow one step commands and was not appropriate for use of rolling walker (RW) or wheelchair (w/c) secondary to impaired safety awareness and agitation. The physical therapist requested CGA for ambulation to maintain safety and prevent future falls. Resident #5's CP was updated on 5/10/15 with interventions to encourage activities and encourage to remain in the dining room while awake. There was no further documentation in the CP r/t the results of the PT screen being completed on 5/19/15 or that assessments were done r/t Resident #5 needing CGA while ambulating. Further review of the INPN revealed that Resident #5 continued to ambulate without assistance from staff; 5/11/15 at 6:04 a.m. and 10:57 a.m.self ambulating. 5/11/2015 at 6:03 p.m.; .observed to walk with top part of her body forward, this writer attempted to get resident to walk upright and resident is unable to follow directions due to forgetfulness and poor cognition. 5/12/15 at 2:50 p.m.; .resident able to ambulate without any difficulty with a slow, steady gait. 5/19/2015 at 4:05 p.m.; .ambulate ad lib.with steady gait.has poor safety awareness. 5/19/15 at 6:20 a.m.; .11:30 p.m.wandering in the hallway and pulled the alarm system at the end of the hallway. 5/20/15 at 3:47 a.m.; .Pacing aimlessly in the hallway. On 5/21/2015 at 1:35 p.m., the INPN revealed that Resident #5 was observed by a CNA to sit down onto the floor. An IR, dated 5/21/15 at 1:20, confirmed the observed fall and noted per staff resident sat herself down onto the floor and scratching the floor and sudden (ly) sat down. Interventions on the IR included to monitor resident's safety when she is ambulating around the unit. A PT screen, dated 5/22/2015 and signed by the Physical Therapist, indicated Resident #5 was not appropriate for PT secondary to inability to follow one step commands and was not appropriate for use of a RW or w/c secondary to impaired safety awareness and agitation. The physical therapist requested CGA for all functional mobility to maintain safety. The fall CP was not signed as reviewed and/or updated after the fall on 5/21/2015. There was no documentation in the CP r/t the results of the PT screen conducted on 5/22/15 or that an assessment was done r/t Resident #5 requiring CGA while ambulating. Further review of the INPN revealed that Resident #5 continued to ambulate without assistance from staff; 5/21/15 at 8:35 p.m.; Resident ambulating on unit when (resident #5) went up to (another resident).and hit (the other resident). 5/22/15 at 8:25 p.m.; .Ambulates around the unit with no complaints. 5/23/15 at 11:16 a.m.; .Residents whereabouts are monitored for safety. 5/23/15 at 2:06 p.m. and 10:22 p.m.; Received resident ambulating in hall of unit., ambulatory up and down hallway without any difficulty. 5/24/15 at 11:22 p.m.; .observed pacing hallways, grabbing onto rails around 4 p.m. 5/25/15 at 6:10 p.m.; .observed to be flipping tables in the dining room. medication was given for agitation. Resident is currently ambulating on the unit. 5/31/15 at 6:39 p.m. and 6/5/15 at 3:41 a.m.; .ambulating on unit., .ambulating in hallway. On 6/11/2015 Resident #5 subsequently sustained a fall. Review of the hospital records, received by the NJ DOH on 7/27/2015. indicated that Resident #5 was admitted to the hospital on [DATE], received pain management on admission; Morphine for a pain scale of 6 and underwent a left bipolar hemiarthroplasty for a displaced subcapital fracture of the left hip. On 7/16/15 at approximately 3:30 p.m., Resident #5 was observed by the surveyor awake, laying in bed and with surgical scar to left femur/hip area intact. Resident #5 was uninterviewable. During an interview with the surveyor on 7/16/2015 the DON confirmed that Resident #5 ambulated freely on the unit with no CGA from the staff prior to the fall on 6/11/2015. Additionally, the DON confirmed that after a fall, a Rehabilitation Referral is made by nursing for a PT screen and the results should be on the MR, however, the PT Department staff should also conduct inservices with the nursing staff r/t the level of assistance that a resident needs. Review of the facility policy titled; Fall Prevention Program and dated 2/17/14, included but was not limited to the following; The fall prevention program aims to provide a safe environment for all residents and reduce risk for falls and/or minimize any injuries that may result for a fall. The facility aims to ensure resident's safety through proper screening and identification of residents at risk for falls and put interventions in place immediately. Care Plans are initiated on admission, then reviewed/revised quarterly and annually thereafter and after each fall incident.Therapy referrals as indicated: indicate how resident fell , any noted injury post fall, level of assistance will be updated and given to nursing from the Therapy Department if there are any changes during treatment. NJAC: 8:39-27.1 (a)

COMPLAINT #: NJ CROSS REFERENCE F 323 Based on interviews and review of the medical record (MR) and other facility documentation, it was determined that the facility failed to update a plan of care (CP) with results of Physical Therapy (PT) Rehabilitation Referrals (PT screens) for 1 of 7 sampled residents (Resident #5). Resident # 5 had a history of [REDACTED]. Rehabilitation Referrals (PT screens) were requested by the Nursing Department and conducted by the PT Department after each fall on 4/9, 5/19 and 5/22/2015. Each PT screen indicated that contact guard assistance (CGA) was needed by Resident #5 for safe ambulation. However, the CP did not reflect CGA. Resident #5 was allowed to ambulate unassisted and subsequently sustained a fall on 6/11/2015 which required pain management, hospitalization and surgery for [REDACTED]. This deficient practice is evidenced by the following; 1. See Example #1. NJAC 8:39-11.1