Every finding on record at Complete Care at Holiday City

Based on interviews, review of medical records, and review of other pertinent facility documents on 5/05/2026, it was determined that the facility failed to maintain a safe environment and to provide adequate supervision to prevent the elopement of a resident (Resident #2) who was assessed to be cognitively impaired and was identified as an elopement risk.Resident #2 exited their secured unit without staff knowledge and eloped from the facility on 4/22/2026 at approximately 8:01 PM. A visitor exited the secured unit at approximately 8:00 PM on 4/22/2026 by entering a code into a keypad allowing Resident #2 to also exit the unit. Resident #2 followed the visitor to the front lobby where the receptionist enabled the front door to open which allowed Resident #2 to exit along with the visitor. The receptionist stated that they have photos of all the residents on elopement risk on the wall at reception desk area, but she did not check the residents photos because she assumed both were visitors. The resident was later found by the police approximately 1 mile away at 8:58 PM and was brought back to the facility at 9:15 PM.The facility's failure to maintain a safe environment and provide adequate supervision to prevent Resident #2 from leaving the facility without staff knowledge, placed this resident as well as all residents at risk for elopement, at risk and at the likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation.The IJ began on 04/22/2026 at approximately 8:00PM, after Resident #2 exited the facility without staff knowledge. The Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON) were informed of the F689 IJ and were provided with the IJ template on 05/05/2026 4:31 P.M.The IJ was Past Non-Compliance (PNC). This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for elopement. A review of the facility's policy titled: Elopement and wandering Residents with an implementation date of 9/1/2024, Under Policy revealed: This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Under Policy Explanation and Compliance Guidelines: 4d. Adequate supervision will be provided to help prevent accidents or elopement. A review of the Facility's Reportable Event (FRE) with an event date of 4/22/2026, which the facility submitted to the New Jersey Department of Health (NJDOH), revealed that at approximately 9:00 PM on 4/22/2026, the facility received a call from the police patrol officer who informed the facility that their resident was outside. The FRE stated that Resident #2 was then escorted to their unit, and that staff assessed the resident and found no abnormalities. According to the police report dated 4/22/2026, at 8:58 PM, the police department was notified by a dispatched emergency call which indicated that they observed an elderly person on the street who appeared disoriented. The police report stated that officers went to the location (approximately 1mile away from the facility) and found the resident. The police stated that the resident could not state what city their home is located and was unsure where they lived. The police retrieved an identification card from the resident which helped locate and contact the resident's family member. The resident's family member then informed the police of the resident lived at the nursing facility. The police returned the resident to the facility on 4/22/26 at 9:15 PM According to the admission Record face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: metabolic encephalopathy (a brain dysfunction caused by systematic illness, organ failure), chronic obstructive pulmonary disease (a progressive, treatable lung disease) and acute kidney failure (a sudden often reversible decline in kidney).According to the quarterly Minimum Data Set (MDS), an assessment tool dated 4/19/2026, Resident #2 had a BIMs score of 5 out of 15, which indicated the resident's cognition was severely impaired. A review of Resident #2's Elopement assessment dated [DATE] at 3:42 PM, indicated that Resident #2 was a risk for elopement. The elopement evaluation stated that Resident #2 answered Yes to the question: has the resident expressed the desire to leave, go home talked about going on a trip, or attempted to pack belongings. The evaluation under behavior, stated that Resident #2 displayed shadowing of staff or residents and hovering at exits.A review of Resident #2's Care Plan (CP) initiated on 4/17/2026, with revision date of 4/28/2026, included that Resident #2 has a history of attempts to leave the facility and may try to leave the building without supervision related to impaired safety awareness, and that the resident wanders aimlessly. The CP included an intervention to make sure all staff are aware of elopement risk. An interview was conducted on 5/05/2026 at 12:53 PM with the Receptionist who stated he worked at the front desk on 4/22/2026 from 3:00 P.M to 8:00 P.M. The receptionist stated that he observed Resident #2 standing with a visitor as the visitor signed out at the kiosk around 8:00 PM on 4/22/2026. He stated that after the visitor signed out, both visitor and Resident #2 walked out of the building. He stated that he assumed they were together, and so, he did not ask them to sign out individually. The Receptionist confirmed that the pictures of residents at risk for elopement were at the front desk, but he did not look at the pictures or question Resident #2. The receptionist further stated that after the elopement on 4/22/2026, they were provided an in-service training on not sharing the exit code with anyone who was not an employee of the facility.The surveyor observed the reception desk area and noted that Resident #2's photo was on the wall next to the receptionist's desk along with other residents' photos.An interview was conducted on 05/05/2026 at 12:09 PM with the LNHA in the presence of the DON. The LNHA stated that visitors should not have access to the code for a secured unit. She stated that the receptionist should have asked about the person standing near the visitor (Resident #2) when the visitor signed out. A review facility's document titled: Investigative Summary and Conclusion (ISC), revealed that Resident #2 followed a family member who was visiting on the secured unit and exited the unit. The ISC stated that the family member visited the facility daily and so, had access to the locked unit's exit door keypad code; and that he used the code to open the unit door on the locked unit without asking staff. The ISC further stated that Resident #2 then followed the visitor down to the front lobby and left the facility by following the visitor. The ISC stated that it was the police officer that called to let the facility know the found the resident in the community near the facility.An acceptable Removal Plan (RP) was received on 5/06/2026 at 2:03 PM, indicating the action the facility would take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice, including: Head count immediately completed at 9:00 P.M by the nursing supervisor with all residents accounted for. Resident #2 was assessed at the time of the incident on 4/22/2026 by nursing supervisor at 9:20 P.M.Head to toe assessment and pain assessment completed with no new findings noted. Resident #2 was placed on 1:1 supervision pending psychiatric review. All doors and windows evaluated for proper function by maintenance Director and Regional administrator on04/22/2026, with no concerns identified. All facility residents reassessed by unit mangers/nursing supervisors for elopement risk on 4/23/2026. Elopement binders reviewed/updated by unit managers and Director of Nursing on each unit and front desk on 4/23/2026. Receptionists were reeducated on 4/23/2026 by the Director of Nursing and designees on Wandering Residents and Elopement, the Elopement Binder, and protocols for allowing visitors out of the facility. Specifically, regarding not allowing visitors to leave without all parties checking out. In-service initiated with all staff on 4/22/2026 by the director of Nursing and Designees on Wandering Residents and Elopement as well as safe exit protocols. This was completed 4/24/2026.Identified visitor was educated by the Administrator on 4/23/2026 to only exit when accompanied by staff and to ensure there is no one existing with him. In-servicing was sent to Applewood families by the Administrator on 5/04/2026. Topics include entering and exiting procedures for the unit and the importance of not allowing any other visitors, staff or residents off the unit with them. On 4/23/2026 a new signage was placed on the doors to the Applewood unit reminding all staff and visitors of the access procedures.This IJ is Past Non-Compliance. The surveyor verified the implementation of the removal plan on site on 05/08/2026 and determined that there is sufficient evidence that the facility corrected the noncompliance on 05/04/2026 and is in substantial compliance at the time of the current survey for the specific regulatory requirement for F689. NJAC: 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) maintain kitchen equipment in a clean and sanitary manner and b.) maintain nourishment room refrigerators in a clean and sanitary manner on 3 of 3 units and was evidenced by the following: On 4/22/25 at 9:48 AM, in the presence of the Food Service Director (FSD) and the Regional FSD, the surveyor observed the following: 1. The microwave had multi-colored dried stuck on debris on the interior ceiling of the unit. The FSD acknowledged it was not properly cleaned according to facility policy. 2. Two convection ovens were soiled with baked on brown coloring on the glass doors and interior of the unit. The FSD acknowledged and stated it was not cleaned according to facility policy. 3. Two steamer units had brown and crusted debris on the interior door and seal of door. The FSD acknowledged and stated it was not cleaned according to facility policy. 4. The six-burner stove top and oven were not clean. The FSD stated the oven was used for warming only, and the surveyor observed food sediment and debris on the interior and the interior door. The surveyor also observed the catch tray that was lined with foil had burnt liquid and food debris covering the entire tray and foil. The FSD acknowledged and stated it was not cleaned according to facility policy. 5. The double holder commercial plate warmer had food debris on the plate warmer section. The body of the unit had sticky brown debris around the rim of the plate warmer. The FSD acknowledged that the unit was not clean and that its purpose was too warm clean plates for distribution to the residents. He further stated it was not cleaned according to facility policy. 6. In the dining room, in the presence of the FSD and RFSD, it was observed to have a portable steam table that consisted of five individual steamer bays that were all filthy. Each bay had clouded white water, orange/brown sediment stuck to the sides of water basin, food particles of vegetables and potatoes were noted in the water. The body of the table had food debris stuck on the glass shield and side walls. The front of the table had a white banquet skirt that was stained. The FSD stated that it was supposed to be cleaned nightly or as needed in between resident dining. The FSD acknowledged and stated it was not cleaned according to facility policy. On 4/24/25 at 9:43 AM, in the presence of the nursing Unit Manager (UM), the surveyor observed on all three of the nursing units in their nourishment rooms, the refrigerators all had sediment in the gaskets of the doors, frozen food spills in the freezer, and dirt on the outside handles. The UM acknowledged and stated it was not cleaned according to facility policy, and that she would contact housekeeping. On 4/24/25 at 10:52 AM the surveyor interviewed the FSD, who acknowledged that the equipment should have been cleaned and maintained in a sanitized way to prevent food borne illness and contamination for safety of the residents. On 4/24/25 at 11:17 AM, the surveyor interviewed the Housekeeping Director (HD), who acknowledged that the pantry equipment should have been cleaned and maintained in a sanitized way to prevent food borne illness and contamination. On 4/24/25 at 12:45 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), who both acknowledged the surveyor's concerns. No additional information was provided. A review of the facility's undated Cleaning of kitchen Equipment Policy policy included Ovens .ensure all debris and grease are removed from interior surfaces . Drip trays; change foil weekly or more frequently if soiled . Steamer; weekly, remove door plates and clean gaskets thoroughly to prevent buildup and maintain a proper seal .Microwave: at the end of each day, clean interior walls and surfaces . A review of the facility's undated Cleaning and Maintaining the steam table policy included all dietary staff are responsible for proper use, cleaning and maintenance of the steam table . NJAC 8:39-17.2(g)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide a resident with nail care during activities of daily living (ADL) care. This deficient Practice was identified for 1 of 2 residents reviewed for ADL care (Resident #52), and was evidenced by the following: On 4/21/25 at 7:54 PM, the surveyor observed Resident #52 sitting in their wheelchair in their room. The resident's fingernails were long in length with dirt underneath, and on their left hand, the 3rd, 4th, and 5th digits (fingers) had a yellow thick discoloration of the nail. On 4/22/25 at 11:24 AM, the surveyor reviewed the medical record for Resident #52. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder and Alzheimer's disease. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated a moderately impaired cognition. The resident required setup or clean-up assistance for personal hygiene. A review of the individualized comprehensive care plan (ICCP) included a focused area for activities of daily living (ADL). The intervention dated 1/10/23, for personal hygiene, indicated one staff member to assist and supervise that tasks have been completed. On 4/22/25 at 10:53 AM, the surveyor interviewed the resident if they preferred their fingernails to be long in length, and the resident stated no. The resident further stated that the last three digits on their left hand hurt to have them cut because they were so thick. On 4/23/25 at 1:16 PM, the surveyor interviewed the resident's assigned Certified Nursing Aide (CNA), who stated it was the responsibility of the CNAs to provide nail care for the resident which included cleaning underneath the nails and cutting the length. The CNA stated that nail care was performed when needed, and she confirmed she did not perform nail care on the resident today. On 4/23/25 at 1:20 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the assigned nurse should do a visual assessment and look at their residents every shift. the LPN stated if there were any issues noted, the nurse needed to make the physician aware and document it. The LPN stated if the physician did not call back soon, then she placed another call out to them. The LPN stated that the nurse also put any new findings on the 24-hour report (a facility document for supervisor) to let management know. On 4/23/25 at 1:34 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that her expectations were for the staff to do a visual assessment every shift, and if there were any issues noted, they needed to make the physician aware and document. The LPN/UM stated the nurse should also update the care plan to reflect any new issues. On 4/24/25 at 10:34 AM, the surveyor interviewed the Director of Nursing (DON), who stated ADL care was performed by the CNAs, but all licensed nursing staff could perform care. The DON further stated that the nursing staff should visualize the resident and their hands prior to performing hygiene care or distributing food trays. The DON continued that the nursing staff should offer and assist the resident to wash their hands prior to eating. On 4/25/25 10:04 AM, in the presence of the survey team, the DON and the Licensed Nursing Home Administrator (LNHA) acknowledged the resident's fingernails were not cut until surveyor inquiry, and the ICCP did not include nail care. No further information was provided. A review of the facility's Activities of Daily Living policy dated 9/1/24, included . a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . NJAC 8:39-27.2 (g)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain the residents' living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 3 of 3 nursing units reviewed for homelike environment (Jefferson-unit, [NAME]-unit, and Applewood-unit), and was evidenced by the following: On 4/24/25 at 9:43 AM, in the presence of the Registered Nurse (RN), the surveyor observed the following in the nourishment room on the [NAME] unit: 1. The back splash and counter had black discoloration the length of the countertop joint. 2. The sink had stains and white discoloration. 3. The counters and cabinets were peeling laminate and chipped paint. 4. The interior of the far-right lower cabinet had a spill that had dried and stained the cabinet with coffee grounds stuck to it. On 4/24/25 at 9:59 AM, in the presence of the Licensed Practical Nurse (LPN), the surveyor observed the following in the nourishment room on the [NAME] unit: 1. The back splash and counter had black discoloration the length of the countertop joint. 2. The countertop right corner was broke, flaking of wood and had a hole in that was approximately 8 inches long. 3. The counters and cabinets were peeling laminate and chipped paint. 4. The inside of the cabinets and drawers had food debris and spilled items that were stuck on. On 4/24/25 at 10:23 AM, in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM), the surveyor observed the following in the nourishment room on the Applewood unit: 1. The back splash and counter had black discoloration the length of the countertop joint. 2. The counters and cabinets were peeling laminate and chipped paint. 3. The inside of the cabinets and drawers had large amounts of food debris and spilled items that were stuck on. On 4/24/25 at 10:25 AM, the surveyor interviewed with the contracted Housekeeping Director (HD), who stated that he had a weekly schedule in place to deep clean the nourishment rooms. The surveyor inquired if he did audits on his staff, and the HD replied, no I do not do audits, but I check the nourishment rooms daily. The surveyor asked if he had seen them this week, and the HD stated no. On 4/24/25 at 11:17 AM, the surveyor interviewed the Regional Maintenance Director (RMD), who stated that he made rounds throughout the facility regularly and there were no plans in place to replace or fix the cabinets and counters at that time. The RMD stated if there was a maintenance issue or something was broken, all staff had access to the electronic maintenance system which provided the maintenance department with a work order if something needed to be fixed. On 4/24/25 at 11:25 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated the only work order in for the facility was for furniture for the resident rooms. The LNHA was unaware of the issue in the nourishment rooms. On 4/24/25 at 12:50 PM, the survey team met with the LNHA and the Director of Nursing (DON), who both acknowledged the surveyor's concerns. They were unable to provide additional information. A review of the facility's Maintenance Inspection policy dated 9/1/24, included .It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary and comfortable environment for residents, staff and the public all opportunities will be correct by maintenance personnel . NJAC 8:39 - 31.2

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care for all residents, accurately. This deficient practice was identified for 3 of 27 residents reviewed for MDS (Resident #73, #99, and #101), and was evidenced by the following: 1. On [DATE] at 10:03 AM, the surveyor reviewed a list of smokers provided by the facility. Resident #73 was identified as a smoker. The surveyor reviewed the medical record for Resident #73. A review of the Admission Record face sheet (an admission summary) revealed that Resident #73 was admitted to the facility with medical diagnoses which included but were not limited to; major depressive disorder, hypertension (high blood pressure), and schizophrenia (disorder that affects a person's ability to think, feel, and behave). A review of the most recent comprehensive MDS dated [DATE], revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which meant the resident had a moderately impaired cognition. A further review in Section J, Health Conditions, the question for tobacco use was marked as no, which meant Resident #73 was assessed as a non-smoker. A review of the resident's Activities assessment dated [DATE], included in the section titled participation, that the resident was a smoker and joined peers at the designated breaks. A review of the resident's smoking contracts, revealed the resident signed a quarterly smoking contract in [DATE]. On [DATE] at 9:39 AM, the surveyor observed the resident outside during a smoking session. On [DATE] at 10:45 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated the resident was a smoker. On [DATE] at 10:12 AM, the surveyor interviewed the MDS Coordinator (MDSC). The surveyor asked how she was informed if a resident was a smoker. The MDSC stated that there would be a smoking assessment, she checked the medical record, and confirmed with the resident during an interview. The surveyor asked if the resident was a smoker and she stated maybe. 2. On [DATE] at 10:21 AM, the surveyor reviewed the MDS list for Resident #99. The list showed the last MDS that was completed for Resident #99 was a quarterly assessment completed on [DATE]. A review of the Admission Record face sheet revealed that Resident #99 had medical diagnoses which included but were not limited to; hemiplegia (weakness of one side of the body), diabetes (high blood sugar), and muscle weakness. A review of the progress notes reflected a note written on [DATE], which revealed the resident was on palliative care (a form of medical care that focuses on providing relief from pain and other symptoms for people with life threatening illness) and expired at the facility on [DATE]. On [DATE] at 10:30 AM, the surveyor interviewed the MDSC regarding Resident #99. The surveyor asked how she was notified of a resident expiration. The MDSC stated she confirmed a resident's death by reading the progress notes and then completed a death in the facility MDS. The surveyor asked the MDSC to look for the death in the facility MDS for Resident #99. The MDSC confirmed there was not one, and stated they missed it. 3. On [DATE] at 7:53 PM, during the initial tour of the facility, the surveyor observed Resident #101 was in bed with their eyes open. The resident told the surveyor that they had a gastrostomy tube (g-tube; a tube inserted through abdomen into the stomach for nutrition feedings). The surveyor reviewed the medical record for Resident #101. A review of the Admission Record face sheet revealed that Resident #101 was admitted to the facility with medical diagnoses that included but were not limited to; hemiplegia (weakness of one side of the body), hypertension (high blood pressure), and dysphagia (difficulty swallowing foods or liquids). A review of the physician's orders included an order for Jevity (liquid nutrition); to administer 70 milliliters (mL) per hour via the g-tube at 6:00 PM, until the total volume has reached 800 mL. A review of the most recent quarterly MDS dated [DATE], revealed that the resident had a BIMS score of 11 out of 15, which meant the resident had moderate cognitive impairment. A further review under section K, Nutrition and Swallowing, it was marked no for feeding tube (g-tube). On [DATE] at 10:40 AM, the surveyor interviewed the MDSC regarding Resident #101's feeding tube. The surveyor asked if the MDS should have included the resident's g-tube, and the MDSC confirmed yes, and that the nurse who that completed the MDS had put a no. The MDSC stated that she would correct the error. NJAC 8:,d+[DATE].2 (d)

Based on observation, interview, and facility document review and in the course of a complaint investigation, the facility failed to serve food at the appropriate temperatures on one of three units (Applewood Unit) in the facility. This failure had the potential for residents to experience untoward effects from eating food not served at the appropriate temperatures. Findings include: An observation was conducted on 02/11/25 at 11:45 AM at which time temperatures were taken o food on the tray line. The temperatures were as follows: -Moreshae Soup 186 degrees -Fritten Vegetable 188 degrees -Tomeolo 166 degrees -Mashed Potatoes 171 degrees -Mixed Vegetables 165 degrees -Eggplant 165 degrees -Whole Milk 39 degrees -Apple Juice 42 degrees -Pudding 37 degrees The meal trays began to be filled at 12:45 PM and ended at 1:00 PM. The trays were followed by the surveyor and the Dietary Manager (DM) to the Applewood unit where they arrived at 1:05 PM. Half of the meal trays were placed in an enclosed food cart while the other half was in an open food cart. The trays were given out by staff to the residents on the floor. At 1:13 PM, the last meal tray was served from the open food cart, and the test tray temperatures were taken. The temperatures are as follows: -Fritten Vegetable 133 degrees -Mixed Vegetables 111 degrees -Moreshae Soup 136 degrees -Whole Milk 53 degrees -Apple Juice 53 degrees -Pudding 48 degrees During an interview on 02/11/25 at 1:15 PM, the DM stated, The cold foods should be no higher than 42 degrees and the hot foods minimum temperature is 135 degrees. During an interview on 02/11/25 at 3:00 PM, the Regional Food Service Director stated, We had received complaints from residents that they were getting cold food. We started taking temperatures every week and we have not had the food temperature problems that we had today. Going forward we will continue to look at our process and improve so that we are not serving cold food. Review of the undated facility's policy Food Temperatures and Holding Policy stated, Guidelines for Holding Food: .Hot food at 135 [degrees] or above . Cold food at 41 [degrees] or below . N.J.A.C. 8:39-17.2 (g)

Based on observation, interview, and review of the facility policy, the facility failed to protect a resident's right to dignity while dining for one out of one resident (Resident (R)18) in a total sample of 22. The facility failed to ensure R18 was dressed and fully covered while in the dining room. This failure placed the resident at risk of a diminished quality of life and embarrassment. Findings included. Review of the facility policy titled, Promoting/Maintaining Resident Dignity, dated 09/01/24 revealed, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R18 was admitted to the facility on [DATE] with diagnoses that included heart failure, irregular heart rhythm, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR revealed R18 had a Brief Interview of Mental Status (BIMS) score of five out of 15 which indicated R18 was severely impaired in cognition. During an observation on 02/11/25 at 12:56 PM, R18 was observed seated at the dining table in a geri chair (a specialized recliner.) He/She was wearing a hospital gown that was untied in the back exposing his/her back to all other residents, family members and staff members when he/she leaned forward to eat. Registered Nurse (RN) 1 was observed to have provided R18 with his/her meal tray, however, she did not tie the hospital gown in the back or cover R18 up with a blanket to prevent further exposure. During an interview on 02/11/25 at 1:10 PM, Unit Manager (UM)2 was asked about R18's exposed back while he/she was eating. UM2 stated, She should have covered him/her up, I will take care of it. During an interview on 02/11/25 at 4:30 PM, the Director of Nursing (DON) stated, Staff should be maintaining residents' dignity by keeping them covered. N.J.A.C. 8:39-4.1(a)(2)

Based on record review, interview, facility investigation, and in the course of a complaint investigation, the facility failed to conduct a thorough investigation in one of one resident to resident altercation (Resident (R)9 and R21) out of a total of 22 sampled residents. This failure had the potential to affect all the residents in the facility who were at risk of abuse. Findings include: 1. Review of R9's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R9 had been readmitted to the facility on [DATE] with the diagnosis of chronic kidney disease, stage five, diabetes mellitus, and anxiety disorder. Review of R9's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 07/14/23 coded R9 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This represents R21 was cognitively intact. R9 was not coded for exhibiting behaviors in the seven day look back period for this MDS. 2. Review of R21's undated Face Sheet located under the Profile tab in the EMR revealed R21 had been admitted to the facility on [DATE] with the diagnosis of diabetes mellitus and adjustment disorder with mixed anxiety and depressed mood. Review of R21's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD)of 06/14/23 coded R21 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This represents R21 was cognitively intact. R21 was not coded for exhibiting behaviors in the seven day look back period. A review of the facility's self-reported dated 08/30/23 of the resident-to-resident altercation investigation was performed. Through this review, on 08/29/23 at 3:00 PM, R9 was wheeling himself/herself down the hall, another resident [R21] spoke to him/her [R9] briefly and then as he/she [R9] passed by he/she [R21] hit him/her [R9] on his/her back [sic]. No injuries occurred. Further review of the investigation revealed a statement from the Administrator and a statement from a staff member that witnessed the exchange between R9 and R21 on 08/21/23. There was also a resident statement that was reviewed. There was no further documentation of statements from the staff that were working with R9 and R21 on the date of this incident nor were there statements from the other residents that could have been interviewed. The Administrator and the staff statements were from staff that are no longer employed at the facility. During an interview on 02/12/25 at 11:00 AM, the present Administrator reviewed the investigation and stated, This is not a complete investigation. There are no other statements from the staff and the residents. I have questions like did [R21] have a psychiatrist or psychotherapy consult, did R21 have any past behaviors like this, and how did R9 feel after this altercation? I just don't see a lot that was done or asked during this investigation. Review of the facility's policy Abuse, Neglect, and Exploitation dated 09/01/24 stated, .Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation . Increased supervision of the alleged victim and residents . N.J.A.C. 8:39-4.1(a)(5)

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for two (Residents (R)5, R10) in a total sample of 21. The facility failed to accurately code the significant change assessment for falls and the quarterly assessment for pressure ulcers for R5. In addition, the facility failed to accurately code pain on the admission assessment for R10. These failures placed the residents at risk of unmet care needs and a diminished quality of life. Findings included. Review of the October 2024 RAI, manual, page 1-5 revealed, .An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations .It is important to note here that information obtained should cover the same observation period as specified by the MDS (minimum data set) items on the assessment, and should be validated for accuracy (what the resident's actual status was during the observation period) by the IDT (interdisciplinary team) completing the assessment . 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R5 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of the significant change MDS located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 01/24/24 revealed R5 was staff assessed to be severely impaired in cognition and had not sustained any falls since the previous assessment. Review of a 12/27/23 fall incident report, provided by the Director of Nursing (DON) revealed R5 had fallen out of bed and sustained a small cut above his/her right eye. R5 was transported to the hospital for evaluation and treatment. Review of the quarterly MDS located in the MDS tab of the EMR with and ARD of 04/25/24 revealed R5 had three Stage 3 pressure ulcers. Review of an 12/20/23 Health Status Note located in the Progress Notes tab of the EMR revealed R5 had one sacral pressure ulcer. There was no other pressure ulcers identified through the EMR from 12/20/23 to 04/25/24. 2. Review of the admission Record located in the Profile tab of the EMR revealed R10 was admitted to the facility on [DATE] with a diagnosis of a right hip fracture. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 11/01/24 revealed that R10 was coded has not been administered either as needed pain medication or scheduled pain medication during the seven-day observation period. In addition, the assessment revealed that R10 had frequent pain and rated his/her pain 10 out 10 (worse pain possible) on the pain scale. Review of the October 2024 Medication Administration Record (MAR) located in the Orders tab of the EMR revealed R10 had been administered Oxycodone (a narcotic pain medication) daily during the observation period. During an interview on 02/13/25 at 9:25 AM, the Regional MDS Coordinator confirmed that R5 and R10's assessments were coded inaccurately. N.J.A.C. 8:39-11.1(h)

Based on observations, interviews, record review, and review of the facility policy and the Resident Assessment Instrument (RAI) manual, the facility failed to develop a comprehensive Care Plan with a person-centered focus, measurable goals, and resident-specific interventions for two (Residents (R)8, and R17) in a total sample of 22. The facility failed to develop a comprehensive Care Plan related to pain for R8. In addition, the facility failed to develop a comprehensive Care Plan related to diabetes and insulin use for R17. These failures placed the residents at risk of unmet care needs and a diminished quality of life. Findings included: Review of the facility policy titled, Comprehensive Care Plans, dated 09/01/24 revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Review of the October 2024 RAI manual, page 1-2 revealed, .Providing care to residents with post-hospital and long-term care needs is complex and challenging work. Clinical competence, observational, interviewing, and critical thinking skills, and assessment expertise from all disciplines are required to develop individualized care plans. The RAI helps nursing home staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. It also assists staff with evaluated goal achievement and revision care plans accordingly by enabling the nursing home to track changes in the resident's status. As the process of problem identification is integrated with sound critical interventions, the care plan becomes each resident's unique path toward achieving or maintaining their highest practicable well-being . 1. Review of R8's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R8 had been admitted to the facility on [DATE] with the diagnosis of end stage renal disease, anemia in chronic kidney disease, and diabetes mellitus. Review of R8's Nursing Progress Notes located under the Progress Note tab in the EMR revealed a note dated 07/31/24 at 10:19 PM which stated, Resident fail [sic] from stretcher doing transport to dialysis. As a result, did not have dialysis [sic] Resident was then transported to [name of hospital] . Right shoulder fracture . Order to put in Sling [sic]. Sling is in place . Review of R8's Care Plan located under the Care Plan tab revealed no documentation of a care plan which had been developed for the fracture of the right shoulder or for pain. During an interview on 02/12/25 at 10:35 AM, Unit Manager (UM)2 confirmed there was no development of a care plan after R8 sustained a right shoulder fracture or for pain after R8 fell from a stretcher during transport to dialysis in 07/31/24. 2. Review of the admission Record located in the Profile tab of the EMR revealed R17 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus, type 2. Review of the annual Minimum Data Set (MDS) located in the MDS tab of the EMR revealed R17 had a BIMS score of 13 out of 15 which indicated that R17 was cognitively intact. In addition, R17 had been administered insulin seven out of seven days during the observation period. Review of the current Order Summary located in the Orders tab of the EMR revealed a physician order, dated 01/24/25 for Insulin Aspart (short-acting insulin) 5 units subcutaneously three times a day for diabetes. In addition, R17 had a physician order, dated 12/19/24 for Lantus (Glargine-a long-acting insulin) 7 units subcutaneously at bedtime for diabetes. Review of the Comprehensive Care Plan located in the Care Plan tab of the EMR did not show a focus, measurable goal, or resident-centered approaches for R17's diabetes and insulin use. During an interview on 02/12/25 at 11:43 AM, Licensed Practical Nurse (LPN) 1was asked who was responsible for the development for the Diabetic Care Plan. LPN 1 stated, The nurses, unit managers, and the MDS coordinator. During an interview on 02/12/25 at 5:00 PM, the Director of Nursing (DON) stated, There should have been a Care Plan developed for R17 for diabetes and insulin. N.J.A.C. 8:39-11.2(i)

Based on record review, and interview and in the course of a complaint investigation, the facility failed to follow physician orders for medications for two of four residents (Resident (R)7 and R22) out of a total sampled of 22 residents. This failure lead to R7 not receiving medications that were ordered by the physician to be given. Findings include: 1. Review of R7's undated Face Sheet located under the Profile tab in the EMR revealed R7 had been admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease, hypertension, and history of cerebral infarction without residual effects. Review of R7's Brief Interview for Mental Status (BIMS) located under the Evaluation tab in the EMR and conducted on 04/29/24 revealed R7 had a score of 15 out of 15 which represented R7 was cognitively intact. Review of R7's Physician Orders located under the Orders tab in the EMR revealed orders dated 04/29/25 for the following medications: -Clopidogrel Bisulfate (Plavix) 75 mg (milligram) Give one tablet by mouth one time a day for blood clot prevention -Folic Acid one mg Give one tablet by mouth one time a day for supplement -Lasix 20 mg Given one tablet by mouth one time a day for fluid retention -Prednisone five mg Give one tablet by mouth one time a day Review of R7's Medication Administration Record (MAR) located under the Orders tab in the EMR and dated for the month of April 2024 revealed these medications were coded as 7 for 04/29/24 which according to the Chart Codes means to refer to Nurses' Notes. Review of R7's Nursing Progress Notes located under the Progress Note tab in the EMR revealed notes dated for 04/29/24 which stated Awaiting delivery for the medications listed above. Review of the Pyxis Inventory which was provided by the facility revealed the medications listed above were available to the staff. During an interview on 02/11/25 at 3:15 PM, Unit Manager (UM)1 stated, They [nurses] have to call the doctor and get approval from him before medications can be ordered from pharmacy. After this approval, the nurse can go to the pyxis and get whatever medications that are needed that are in the pyxis and give to the resident. If the nurse does this, and it is past the time the resident was scheduled to get the medication, then the nurse has to get a one-time order for it to be given off schedule. This should be documented in the nurses' notes. During an interview on 02/11/25 at 4:00 PM, the Director of Nursing confirmed that Clopidogrel Bisulfate (Plavix). Folic Acid, Lasix, and Prednisone were available in the pyxis and could have been administered to the resident as ordered by the physician. 2. Review of the admission Record located in the Profile tab of the EMR revealed R22 was admitted to the facility on [DATE] with a diagnosis of Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 11/15/24 revealed R22 had a BIMS score of 14 out of 15 which indicated he/she was cognitively intact. During a medication pass observation on 02/11/25 at 7:50 AM, LPN7 administered Fluticasone (an allergy medication) 50mcg via nasal spray to R22. LPN7 was not observed to have shaken the container prior to administration. When she inserted the nozzle into the left nostril, she was unable to get any medication out. She then removed the nozzle after attempting several times and then shook the medication bottle and said it was empty. LPN7 then returned to the medication cart and retrieved an additional bottle of Fluticasone. LPN7 returned to R22 and inserted the nozzle into the right nostril and pumped three times. During an interview on 02/11/25 at 8:00 AM, LPN7 was asked why she administered several sprays into the left nostril. LPN7 stated, The bottle was empty, but I did get some out. LPN7 was asked what the physician order state on how many times the medication was to be administered in each nostril. LPN 7 stated, One in each nostril. LPN7 was asked why she gave three sprays in the right nostril instead of one. LPN7 stated, It wasn't coming out. LPN7 was asked why she did not shake the bottle first before administering the medication. LPN7 stated, You don't need to shake it. During an interview on 02/11/25 at 9:05 AM, Unit Manager (UM)2 was told about the medication pass observation with LPN7. UM2 stated, If the order reads one spray, then do only one spray. During an interview on 02/11/25 at 11:30 AM, the DON was told about the medication pass observation. The DON stated, Fluticasone should be shaken prior to administration. The DON confirmed that there was an error in administering the medication. N.J.A.C. 8:39-11.2(b)

Based on record review, and interview, the facility failed to review and revise a care plan for insulin for one out of a total of 22 sampled residents(Resident (R)16). This failure had the potential for R16 not to receive the necessary care. Findings include: Review of R16's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R16 had been admitted to the facility on [DATE] with the diagnosis of diabetes mellitus and displaced fracture of the upper end of the left humerus. Review of R16's admission Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 02/04/25 revealed R16 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This represented R16 was cognitively intact. R16 was also coded as having received insulin during the seven day look back period. Review of R16's Physician Orders located under the Orders tab in the EMR revealed an order dated 01/29/25 for Insulin Glargine inject 15 units subcutaneously at bedtime for diabetes mellitus. Review of R16's Care Plan located under the Care Plan tab in the EMR dated 02/10/25 which stated, The resident has Diabetes Mellitus. The interventions were Fasting Serum Blood Sugar as ordered by the doctor, Monitor/document/report PRN [as needed] and s/s [signs/symptoms] of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd [abdominal] pain. Kussmaul breathing, acetone breath (smells fruity), stupor, coma [sic], and Monitor/document/report PRN [sic] any s/s of hypoglycemia: Sweating, tremor, Increased [sic] heart rate (tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait [sic]. There was no documentation R16 was taking insulin at bedtime in the care plan. During an interview on 02/12/25 at 2:30 PM, asked Unit Manager (UM)1, if R16 was receiving insulin should that be included on the care plan and UM1 stated, Yes, it should be. During an interview on 02/12/25 at 1:30 PM, the Director of Nursing stated, [R16] was receiving insulin so yes, the insulin should have been included in the care plan. N.J.A.C. 8:39-27.1(a)

Based on record review, interview, document review the facility failed to follow professional standards in diabetic management of two of four residents (Resident (R)16 and R17) reviewed out of a 22 total sampled residents. This failure had the potential for residents that have diabetes to be mismanaged in their care. Findings include: 1. Review of R16's undated Face Sheet located under the Profile tab in the electronic medical record revealed R16 had been admitted to the facility on [DATE] with the diagnosis of diabetes mellitus. Review of R16's admission Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 02/04/25 revealed R16 was coded as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This represented R16 was cognitively intact. R16 was also coded as receiving seven injections of insulin during the seven day look back period. Review of R16's Physician Orders located under the Orders tab in the EMR revealed an order dated 01/29/25 for Lantus 15 units subcutaneously at bedtime for diabetes mellitus. Review of R16's Care Plan located under the Care Plan tab in the EMR revealed a care plan dated 02/10/25 which stated, The resident has Diabetes Mellitus. Interventions were Fasting Serum Blood Sugar as ordered by the doctor, Monitor/document/report PRN [as needed] and s/s [signs/symptoms] of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd [abdominal] pain. Kussmaul breathing, acetone breath (smells fruity), stupor, coma [sic], and Monitor/document/report PRN [sic] any s/s of hypoglycemia: Sweating, tremor, Increased [sic] heart rate (tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait [sic]. There was no documentation R16 was taking insulin at bedtime in the care plan. Review of the January and February 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR), weights/vitals, and progress notes did not reveal documentation of blood sugars to be obtained for monitoring. Review of R16's Comprehensive Metabolic Panel dated 02/06/25, located under the Results tab in the EMR revealed a blood sugar level of 206. This result was alerted as being High by the laboratory. There was no documentation to show the physician or nurse practitioner were notified of the blood sugar result. Review of the Physician Progress Note dated 01/30/25 at 10:51 AM revealed R16 had been seen however, the progress note did not show that the physician/Nurse Practitioner had addressed the diabetes or insulin usage. No order was given for blood sugar monitoring. During an interview on 02/12/25 at 11:44 AM, Licensed Practical Nurse (LPN)2 was asked when you have a resident on insulin, how do you determine the effectiveness of the insulin you are giving? LPN2 replied, If I don't see signs of hypo or hyperglycemia. LPN2 was asked when a resident is admitted to the facility and is on long-acting insulin, and you do not see orders for blood glucose monitoring, what do you do? LPN2 stated, I call the doctor and ask if he wants to continue the medication or change it. During an interview on 02/12/25 at 1:57 PM, Physician 1 stated, Blood sugars should be done on a daily basis. That is the standard that we do. If there are no blood sugars ordered, then the nurses missed it as well as we missed it. During an interview on 02/12/25 at 3:30 PM, the Director of Nursing (DON) stated, The nurses will only do blood sugars if they are ordered by the physician. I see what you are saying, and I don't disagree. But the nurses won't be doing blood sugars unless they have been ordered by the physician to do so. 2. Review of the admission Record located in the Profile tab of the EMR revealed R17 was admitted to the facility on [DATE] with diagnoses that included diabetes, chronic obstructive pulmonary disease (COPD) and heart disease with heart failure. Review of the annual MDS located in the MDS tab of the EMR with an ARD of 11/25/24 revealed R17 had a BIMS score of 13 out of 15 which indicated she was cognitively intact. The assessment further showed that R17 had been administered insulin seven out seven days during the observation period. Review of the Weights and Vitals tab in the EMR revealed R17 had fingerstick blood sugar (FBS) monitoring three times daily. Review of the Order Summary' located in the Orders tab of the EMR did not show a physician order to obtain the FBS. During an interview on 02/12/25 at 11:15 AM, Licensed Practical Nurse (LPN)1 was asked if R17 was receiving FBS daily. LPN1 stated, When he/she came back from the hospital, he/she came back without orders to do the FBS. During an interview on 02/12/25 at 2:28 PM, Physician 2 stated, The expectation is that when a resident has insulin orders, there should be a sliding scale to check the FBS. I was not aware that he/she did not have FBS orders. It is the nurses' responsibility to tell me this. Review of the undated facility policy titled, Diabetes-Clinical Protocol revealed, . For the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day (for example, before breakfast and lunch as necessary); monitor 3-4 times a day if on an intensive insulin therapy or sliding-scale insulin . Monitor A1C on admission . Review of Diabetes Management found at website https://www.lantus.com/diabetes-management stated, .Lantus should be taken once a day at the same tine every day. Test your blood sugar levels while using insulin, such as Lantus . N.J.A.C. 8:39-11.2(b)

NJ Complaint # 154756 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who sustained a fracture of the distal humerus (elbow) from a fall was readmitted to the facility from the hospital with a soft cast received appropriate care and services which included physician visits and assessments associated with a cast every shift that developed into a mechanical device pressure injury with the beginning stages of necrosis (death to all or most of cells in a tissue) which required wound care and antibiotic treatments. This deficient practice was identified for 1 of 27 residents (Resident #20) reviewed for quality of care, and was evidenced by the following: On 3/22/23 at 1:40 PM, the surveyor interviewed Certified Nursing Aide (CNA #1) who stated Resident #20 was a hospice resident who had recently passed. CNA #1 continued that last year, the resident had a fall in the facility and was sent to the hospital for treatment, and returned to the facility with a wrist fracture and wrap on their arm. CNA #1 continued that one day went she went to assist CNA #2 in providing activities of daily living (ADL) care, she noticed a foul smell coming from the arm as well as observed black discoloration in the skin under the wrap. CNA #1 continued it was the worst smell she ever smelled. CNA #1 stated she was informed by the previous Unit Manager that the hospital discharge instructions did not include the wrap, so the facility had no idea how to care for the wrap, so it probably remained on the resident for six weeks untouched. CNA #1 stated she was not a nurse, but heard there should have been some sort of treatment. On 3/22/23 at 2:04 PM, the surveyor interviewed CNA #2 who confirmed she cared for Resident #20 and was with CNA #1 the day they discovered the foul smell from Resident #20. CNA #2 continued that the resident had a fall in the facility that he/she was in the hospital for maybe two weeks and returned with a wrap on their wrist. CNA #2 stated when she went to perform ADL care with CNA #1; they observed a rotten smell that smelled like a dead rat, but she could not recall who the nurse was who cared for the resident that she informed. CNA #2 stated that the resident had a dressing on their arm that should have been taken care of, but it was not. CNA #2 stated she was not a nurse, so it was not her responsibility to change the dressing, but she cleaned the resident around it. CNA #2 stated if she saw something different or smelled something different, she had to inform the nurse, which she did. The surveyor reviewed the closed medical record for Resident #20. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in January of 2020 with diagnoses which included repeated falls, age-related osteoporosis, moderate protein-calorie malnutrition, and essential hypertension (high blood pressure). A review of the electronic Progress Notes reflected the following notes: An Admission Summary dated 2/9/22 at 7:52 PM, included the resident was received via stretcher with two attendants; [he/she] was alert and oriented, some forgetfulness, maximum assistance of two-person with all ADLs and mechanical lift for all transfers. Resident had a soft [elastic bandage] wrap splint to left upper arm, finger warm to touch; good capillary refills (a test performed on the nail beds to assess the blood flow through peripheral tissues). Opening noted to scrum (lower back) two centimeters by two centimeters (2 cm x 2 cm), house cream applied for weekly wound consultant .All medications verified and read back to Physician #1. An Admission Summary dated 2/13/22 at 6:29 AM, included admission day four; resident was alert and oriented with periods of forgetfulness; total care of two-person assistance required. [Elastic bandage] wrap splint to left upper arm intact, no signs or symptoms of infection. An Admission Summary dated 2/13/22 at 10:13 PM, included admission day five; resident had an [elastic bandage] wrap splint to left upper arm intact, no signs or symptoms of infection. An Admission Summary dated 2/14/22 at 6:42 AM, included admission day five; resident had an [elastic bandage] wrap splint to left upper arm intact, no signs or symptoms of infection. A General Note dated 3/1/22 at 11:01 AM, included change of primary physician to Physician #2; Physician #1 no longer coming to the facility. A Health Status Note dated 3/17/22 at 2:33 PM, written by the Unit Manager/Licensed Practical Nurse (UM/LPN) included during morning care being rendered, CNA noted to have a foul smell coming from left forearm. Resident previously had a fracture with a soft cast applied. Registered Nurse (RN #1) assessed, noted [stretch conforming gauze] wrap unraveled, able to visualize end of the soft cast, right above right wrist; skin appears darkened in color, with foul smell coming from the [elastic bandage] wrap and at the end of the soft cast. Resident noted no pain during RN #1's assessment. Made the Nurse Practitioner (NP #1) aware of area of concern who ordered a wound consultation. New orders received by the NP #1 to remove soft cast and [elastic bandage] wrap; obtained and completed. Wound Care NP conducted a televisit (visit conducted via video conference rather than in person) immediately with new recommendations to cleanse left forearm with normal saline solution; apply medihoney; apply gauze dressing and abdominal gauze pad (used to absorb heavily draining wounds) and wrap with stretch conforming gauze wrap daily. Follow-up with a televisit with the Orthopedic Physician on 3/25/22. A review of the March 2022 Medication Administration Record (MAR) included the following physician's orders (PO) for Augmentin (an antibiotic): A PO dated 3/17/22 and discontinued 3/21/22, for Augmentin tablet 500-125 mg; give one tablet by mouth every twelve hours for twenty-eight administration prophylactic. A PO dated 3/21/22 and discontinued 3/24/22, for Augmentin tablet 500-125 mg; give one tablet every twelve hours for mechanical device pressure injury for twenty-eight administrations until finished. A PO dated 3/24/22 and discontinued 3/25/22, for Augmentin tablet 500-125 mg; give one tablet by mouth every twelve hours for pemphigus (a disease that causes blistering of the skin) for twenty-eight administrations until finished. A PO dated 3/25/22, for Augmentin tablet 500-125 mg; give one tablet by mouth every twelve hours for pemphigus until 3/27/22 at 11:59 PM. A further review of the March 2022 MAR revealed a PO dated 2/18/22, for oxycodone hydrochloride 5 mg capsule (a narcotic pain medication); give one tablet three times a day for pain related to unspecified fracture of the lower end of left humerus (elbow), subsequent encounter for fracture with routine healing. During the time period of 3/17/22 to 3/27/22 when the resident received their antibiotic, it was documented on seventeen shifts that the resident had a pain level of seven, eight, or nine, which indicated severe pain. A review of the hospital Discharge Instructions dated 2/9/22, included follow-up with Orthopedic Physician as needed and with Physician #1 (name crossed-out in pen with handwritten Physician #2) in two days. (Physician #2 was not the resident's primary physician until 3/1/22 as documented in the Progress Notes.) The Discharge Instructions also included the resident had a humerus fracture (a break in the lower end of the upper arm bone) treated with immobilization. Instructions included if you have a cast check skin around the cast everyday .If you have a splint or sling: wear the splint or sling as told by your doctor. Remove it only as told by your doctor. Loosen the splint or sling if your fingers: tingle; become numb; turn cold and blue. Keep the splint or sling clean and dry. A review of the Accident/Incident Report Checklist dated 3/17/22, included on 3/17/22 at 1:24 PM, the resident had a skin incident. The nursing description included I was called to the resident's room by the CNA that noted during care a foul smell coming from the resident's left arm (under soft cast); soft cast removed. Skin was observed redness, slough (nonviable tissue that occurs as a byproduct of the inflammatory process), and darkness noted to wound bed with small serosanguinous drainage (wound drainage that is yellowish with small amounts of blood) coming from the wound. Resident area noted to be an open pemphigus blister that opened up and was now showing signs and symptoms of infection. Immediate actions included x-ray taken of left arm; soft cast removed; wound care consultation completed and found pemphigus bolus blister that opened up leading to the beginning signs of necrosis (death of most or all cells in a tissue due to disease, injury, or failure of blood supply). On 3/23/23 at 1:50 PM, the surveyor requested from the Director of Nursing (DON) for all Physician Notes and Nurse Practitioner Notes for Resident #20 from last standard survey dated 5/11/21. On 3/27/23 at 9:25 AM, the surveyor reviewed all Physician and Nurse Practitioner Progress Notes provided by the DON as requested. There were no notes provided by the DON from either a physician or nurse practitioner from 10/6/21 until 5/26/22 with a progress note dated 5/26/22 from Physician #2. On 3/27/23 at 9:58 AM, the surveyor reviewed the documentation provided with the DON and requested any physician or nurse practitioner notes from 10/21 through 5/22, as well as the facility's physician visit policy. On 3/27/23 at 11:42 AM, the DON informed the surveyor that the Licensed Nursing Home Administrator (LNHA) found additional physician documentation in the closed medical record that was provided. On 3/27/23 at 12:04 PM, the surveyor reviewed the additional two Physician Progress Notes written by Physician #2 from 3/18/22 and 4/7/22. The note dated 3/18/22 included the resident was transferred to our service; resident was undergoing wound care treatment and was on Augmentin for left forearm wound following-up with Orthopedic Physician. On 3/28/23 at 8:52 AM, the DON informed the surveyor that she had thought Resident #20 had refused to follow-up with the Orthopedic Physician when he/she returned from the hospital in February of 2022, but stated she was unable to locate any documentation to confirm. The DON stated that she reached out to NP #1 to see if he had any additional documentation. On 3/28/23 at 10:30 AM, the DON informed the surveyor that Physician #1 was the resident's primary physician who stopped seeing residents at the facility, but she could not speak to when Physician #1 stopped seeing residents. The DON continued that NP #1 was seeing Physician #1's residents and then Physician #2 took over. The DON stated NP #1 was still at the facility, and the facility had reached out to him. At this time, the surveyor requested NP #1's phone number. The DON continued that Physician #1 did not document in the electronic medical record; she documented all her notes on paper. The surveyor asked how long the facility was required to maintain a resident's medical record after discharge or death, and the DON stated she thought ten years. The surveyor then stated so then the facility should have all of Resident #20's medical record maintained, and the DON confirmed yes. The DON stated she had reached out to Physician #1's medical practice to request any documentation from this resident, and she was still waiting to hear back. The surveyor requested the phone number for RN #1 and the DON informed the surveyor the nurse had passed. The surveyor requested the phone number for the UM/LPN, and the DON stated she no longer worked at the facility but would provide the nurse's phone number. On 3/28/23 at 10:48 AM, the LNHA provided the surveyor with all of Physician #1's progress notes for Resident #20. The LNHA confirmed the last documented visit by Physician #1 was from 10/15/21. This meant the resident was not seen by a primary physician from 10/15/21 until 3/18/22, when the resident was found to have a foul smelling wound with the beginning signs of necrosis. On 3/28/23 at 11:17 AM, the surveyor requested from the DON the wound consultation note from 3/17/22 and the orthopedic visit from 3/25/22. At this time, the DON provided the surveyor with NP #1 and the UM/LPN's telephone numbers. On 3/28/23 at 11:19 AM, the surveyor interviewed the UM/LPN via telephone who confirmed she no longer worked at the facility since July of 2022. The UM/LPN stated she recalled Resident #20, and the resident returning from the hospital. The UM/LPN stated she thought the resident had a soft white cast, but was unsure if the nurse could remove the cast. The UM/LPN stated she did not recall Physician #1 seeing the resident upon return from the hospital, and she recalled the resident developed a wound with the cast, but she could not speak to or recall specifics. The UM/LPN stated she could not speak to any treatments the resident received or how the wound developed. On 3/28/23 at 11:25 AM, the surveyor attempted to interview NP #1 via telephone with no response. The surveyor requested NP #1 to call back. On 3/28/23 at 11:34 AM, the surveyor interviewed the Director of Rehabilitation (Rehab) who stated a soft [elastic bandage] splint was an elastic bandage wrapped around the wrist. The Director of Rehab continued that depending on the physician's orders would determine if the wrap was removed, and there would be a follow-up visit with the physician. The Director of Rehab stated nursing would generally do skin checks by removing the splint with a physician's order. The Director of Rehab stated that a soft cast would not be worded as an [elastic bandage] wrap; and generally speaking, an elastic bandage wrap would be removed with physician's orders. If the resident was admitted to the facility with no orders regarding the wrap, nursing would be expected to follow-up with the physician. The Director of Rehab stated the resident did receive treatment from rehab when he/she returned from the hospital, but it was for a leg fracture. According to the notes, the resident had a distal humerus fracture; which would be at the elbow portion of the arm. The Director of Rehab stated she would find additional information for the surveyor regarding what type of cast Resident #20 had. On 3/28/23 at 12:00 PM, the surveyor received the Orthopedic Physician's consultation report from 3/25/22. The Orthopedic Physician indicated that the visit was a televisit and the resident was observed immobilized with pillows and a sling; the resident had no complaints; and the facility obtained x-rays. Services performed was a follow-up visit. Instructions included resident's x-ray was unavailable for review and to send a copy when available; maintain sling; and follow-up in one month. On 3/28/23 at 1:21 PM, the Director of Rehab informed the surveyor that the resident had a humerus fracture at the distal end (elbow) that had a soft cast. The soft cast cradled the elbow and surrounding area, and then conforming gauze wrap was wrapped around that and the surrounding area; and then an [elastic bandage] was wrapped on top of that. The Director of Rehab stated nursing staff needed to unwrap the bandage to check the skin underneath, but she was unsure how often the nurse was required, but stated there would need to be a physician's order. The surveyor reviewed the Orthopedic Physician's consultation from 3/25/22 with the Director of Rehab who stated the resident could not have been in a sling during this appointment because his/her elbow was positioned straight in the hard portion of the cast. The Director of Rehab continued that a fracture at the other end of the humerus bone would result in a sling. On 3/29/23 at 8:33 AM, the surveyor attempted again to interview NP #1 via telephone with no response. The surveyor left a message to call back. On 3/29/23 at 9:15 AM, the surveyor interviewed the Medical Director (MD) via telephone who stated physicians were expected to complete an in-person visit and complete a health and physical with forty-eight hours of resident being admitted or readmitted from the hospital to the facility. The MD stated residents also needed to be seen monthly by their physician, but after the initial visits, a nurse practitioner could alternate monthly visits. The MD stated that the nurse practitioner could not see the resident monthly in place of the physician or complete the health and physical; the physician was expected to oversee the resident's care with the assistance of a nurse practitioner. The MD stated the physician and nurse practitioner were both expected to document in the resident's medical record during each visit. The surveyor asked the MD in terms of professional standards of practice, what was the expected process when a resident was admitted to the facility with a soft cast. The MD stated first the physician had to review the medical record and the x-ray, ensure there was an Orthopedic Physician involved and make a follow-up appointment. The MD stated you would look at the resident's pain levels and determine if pain management needed to be done. The physician ordered the nurse to check capillary refills, ensure skin was intact, and complete assessments; it would be the Orthopedic Physician's decision if the cast was removed. The MD stated that was why it was important for the health and physical to be completed within forty-eight hours of admission to ensure the proper treatment. The MD stated Physician #1 had retired from practicing, and stated Resident #20 should have been seen by the physician when they returned from the hospital; it was not good medical practice. The MD stated he should have been made aware by the facility if the resident was not seen, and he would have seen the resident himself. The MD stated NP #1 is a nurse practitioner from the insurance company and was not one of the physician's nurse practitioners. The MD continued NP #1 saw acute issues; and the attending physician was ultimately responsible for the care of the resident. The surveyor continued to review the closed medical record for Resident #20. A review of the Order Summary Report dated as of 2/10/22, did not include skin checks every shift, or any additional assessments under the soft cast. A review of the corresponding February 2022 and March 2022 MARs and Treatment Administration Records (TAR) did not include skin checks every shift, or any additional assessments for the soft cast. On 3/29/23 at 10:58 AM, the DON informed the surveyor that the facility did not have a health and physical policy and they would provide the surveyor with a skin assessment policy. On 3/29/23 at 11:19 AM, the surveyor interviewed the DON who confirmed NP #1 worked as a nurse practitioner for the insurance company and saw residents with acute issues; he was not part of any of the attending physicians' practices. The DON continued upon admission or re-admission to the facility, the physician was notified of the resident's admission and a call was placed to review medications and order any laboratory tests. The physician was expected to examine the resident within twenty-four to forty-eight hours of admission or re-admission and complete and health and physical in the progress notes. The DON stated it was not the nurse's responsibility if the physician did not come in to see the resident; it would be the responsibility of the LNHA. The DON continued the nurse as a courtesy could contact the physician, but it was ultimately the LNHA's responsibility. The surveyor asked the DON what the expectation was if a resident was admitted with a cast, and the DON stated usually the nurse would not touch the cast until there was a follow-up with an Orthopedic Physician. The surveyor asked if there should be any type of assessments completed or skin assessments, and the DON stated should be a skin assessment around the cast but cannot look underneath the cast. The DON stated usually on the discharge instructions, there would be a follow-up with the Orthopedic Physician, and it was the responsibility of the Unit Clerk to make a follow-up appointment. The DON acknowledged there was no documentation that the resident refused to see the Orthopedic Physician upon return from the hospital, and he/she was not seen until 3/25/22. The DON stated Resident #20 had a soft cast with an [elastic bandage] wrapped over it. The DON continued the resident developed a blister underneath the cast that could not be seen, until the CNA noticed the foul smell and it was removed. The surveyor informed the DON they were told it smelled like a dead rat and the DON confirmed she was told that too. The DON stated she would follow-up with NP #1 to determine what happened. On 3/29/23 at 11:47 AM, the surveyor interviewed LPN #1 who stated she had been at the facility for almost a year and was not familiar with Resident #20. The surveyor asked LPN #1 in terms of standards of practice, what was a nurse expected to do for a resident with a cast. LPN #1 stated the nurse had to ensure the cast was not too tight, no swelling or cutting off of circulation by placing three fingers under the cast. They needed to perform capillary refills which was a three second restriction time on the capillary refills to the nail bed. LPN #1 continued for a soft cast would look around the cast for discoloration. LPN #1 stated if the cast was too tight, it could cause swelling which could result in nerve damage. LPN #1 stated this would have to be done every shift, and it required a physician's order, and sometimes the physician ordered the wrap to be changed. LPN #1 stated if there was no order for the resident, the nurse was expected to call the physician to obtain an order because there was care that was expected with any cast. On 3/29/23 at 2:41 PM, the survey team met with the LNHA and DON. The surveyor requested a timeline which included supporting documentation for Resident #20 from the time they were readmitted to the facility on [DATE] with the soft cast until they developed a wound with the beginning of necrosis on 3/17/22 including what measure were taken to prevent the wound. The surveyor also informed administration they made multiple attempts to contact NP #1, and they had not received a call back. On 3/30/23 at 10:02 AM, the DON in the presence of the LNHA stated she was still typing the timeline and would be completed in ten minutes. The DON continued NP #1 emailed additional notes that she had to review first. The surveyor asked the DON in accordance with professional standards of practice, what assessments were completed for a resident with a cast. The DON responded capillary refills to check circulation; checking warmth of extremities because if there is a cast, you need to know if something was wrong to inform the physician immediately; and put two fingers underneath the cast to ensure there was no edema. The surveyor asked how often these assessments should be completed by nursing, and the DON responded every shift. The surveyor asked if the nurse needed a physician's order for these assessments, and the DON responded yes, and she confirmed the resident had no order and could not speak to why. The DON continued the nurse should have called the physician to obtain an order. The DON confirmed no physician including Physician #1 or #2 saw the resident when he/she returned from the hospital. The DON stated a physician should complete the health and physical within twenty-four to forty-eight hours of admission. The DON acknowledged that a physician should have been seeing the resident because the physician was ultimately responsible for the care of the resident and not NP #1. The surveyor asked when a resident typically followed-up with an orthopedic physician, and the DON stated within one to weeks of admission with a cast. The DON confirmed there was no documentation that an appointment was scheduled, or the resident refused. The DON acknowledged there were missing steps with this cast that should have been done. On 3/30/23 at 11:11 AM, the DON informed the surveyor the notes provided by NP #1 were not during this time period. The DON provided the surveyor with the timeline, and confirmed there was nothing done for the cast. The DON confirmed the facility did not have a policy regarding cast care. The surveyor did not receive a return phone call from NP #1. A review of the facility's Physician Services Policy and Procedure dated 2020, included each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs .the facility shall ensure that the medical care of each resident is supervised by a physician; and another physician supervises the medical care of residents when their attending physician is unavailable .each resident shall be seen by a physician at least every 30 days for the first 90 days after admission and at least once every 60 days after. A review of the facility's Physician's Services policy dated updated 1/2023, included the resident's attending physician participates in the resident's assessments and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident .the physician will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage . A review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy dated updated 1/2023, included the physician will help identify factors contributing or predisposing residents to skin breakdown . NJAC 8:39-27.1(a)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure residents who received dialysis treatments and were on fluid restriction diets received the appropriate amount of fluids daily in accordance with their physician's orders. This deficient practice was identified for 2 of 2 residents (Resident #35 and #80) reviewed for dialysis, and the evidence was a follows: 1. On 3/20/23 at 11:34 AM, the surveyor observed Resident #80's room, and the resident was not in his/her room. Certified Nursing Aide (CNA #1) informed the surveyor that Resident #80 was currently out of the facility at their dialysis appointment. The surveyor observed on the resident's tray table two four-ounce cups of cranberry juice, one sixteen-ounce disposable cup of water with a lid and straw, and one empty eight-ounce hot beverage mug. On 3/21/23 at 11:39 AM, the surveyor observed Resident #80 sitting in their room being administered oxygen via a nasal cannula. The resident informed the surveyor that they were at their dialysis appointment yesterday, and that their dialysis chair time was changed from leaving the facility at 3:00 PM to now leaving at 11:00 AM. The resident stated he/she went to dialysis three times a week on Monday, Wednesday, and Friday for four hours. The surveyor observed on the resident's tray table a sixteen-ounce disposable cup of water with a lid and straw, an eight-ounce cup of cranberry juice labeled Monday 3/21/23, and an eight-ounce plastic mug with a lid labeled cranberry juice. The surveyor asked the resident if they were on a fluid restriction diet because of their dialysis treatments, and the resident stated he/she was unaware. The resident continued some days yes and somedays no; some days told cannot have soup and then the doctor the next day says can have soup. The resident informed the surveyor he/she would not drink the cranberry juice labeled Monday 3/21/23, since it was sitting out too long. The resident also confirmed he/she always received the sixteen-ounce water cup with a straw and lid every day, and he/she drank out of that. The surveyor reviewed the medical record for Resident #80. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in February of 2023 with diagnoses which included muscle wasting and atrophy, essential hypertension (high blood pressure), unspecified protein-calorie malnutrition, heart failure, unspecified kidney failure, and dependence on renal dialysis. A review of the admission Minimum Data Set (MDS), an assessment tool dated 2/16/22, reflected the resident had a brief interview for mental status (BIMS) score of a 15 out of 15, which indicated a fully intact cognition. A further review included the resident received dialysis treatments while a resident at the facility. A review of the March 2023 Medication Administration Record (MAR) included a physician's order (PO) dated 3/9/23 and discontinued 3/20/23, for a 1500 milliliter (mL) fluid restriction (1140 mL dietary and 360 mL nursing) with breakfast four-ounces (4 oz) milk, 4 oz sugar free cranberry juice, 6 oz tea; lunch 6 oz tea, 4 oz sugar free cranberry juice; 2:00 PM 4 oz sugar free cranberry juice; and dinner 6 oz super soup (soup fortified with extra calories) and 4 oz sugar free cranberry juice. A review of the 3/21/23 day shift signed by nursing reflected the resident received 120 mL of fluids by nursing during that shift. This did not correspond with the sixteen-ounces of water observed on the resident's tray table. A review of the Order Summary Report included a PO dated 2/10/23 for fluid restriction diet. An additional PO dated 3/21/23, included 1500 mL fluid restriction (1140 mL dietary and 360 mL nursing) with breakfast 4 oz milk, 4 oz sugar free cranberry juice, 6 oz of tea; 10:00 AM 4 oz sugar free cranberry juice; lunch 6 oz tea, 4 oz sugar free cranberry juice; dinner 6 oz super soup and 4 oz sugar free cranberry juice. Nursing could provide 120 mL of fluids every shift. A review of the corresponding March 2023 MAR reflected the nurse had signed every shift from 3/21/23 until review of 3/26/23, that the resident received 120 mL of fluid during their shift except for the following shifts: 3/21/23 night shift 100 mL 3/22/23 day shift 100 mL 3/22/23 night shift 100 mL 3/26/23 night shift 60 mL This did not correspond with the sixteen-ounce disposable cup of water observed by the surveyor on the day shift for 3/21/23. A review of the individualized person-centered care plan included a focus area dated initiated 2/10/23 and revised 3/9/23, for I have a potential nutritional problem with regards to end stage renal disease on hemodialysis, congestive heart failure (chronic condition in which the heart does not pump blood as well as it should), diabetes mellitus, chronic obstructive pulmonary disease (restriction of the airways and difficulty breathing), and depression. Interventions included to provide a 15000 mL fluid restriction with 1140 ML dietary and 360 mL nursing; hemodialysis on Mondays, Wednesdays, and Fridays; and provide, serve diet as ordered. On 3/27/23 at 10:58 AM, the surveyor observed the resident at the nurse's station. The resident was informing the Registered Nurse (RN) that he/she was leaving for their dialysis treatment, and they had not received their turkey on rye bread sandwich to take with them. The RN informed the resident he would obtain from the kitchen. On 3/27/23 at 11:02 AM, the surveyor interviewed CNA #1 who stated that residents received sixteen-ounce disposable water cups with straws and lids every shift, and she changed the water on her shift. CNA #1 continued she refilled water cups throughout her shift as needed. The surveyor asked how she would know if the resident was on a fluid restriction, and CNA #1 responded by their meal ticket. The surveyor asked if any of the residents on her assignments had fluid restrictions, and CNA #1 stated no. CNA #1 confirmed she was Resident #80's assigned aide as she proceeded into the resident's room to clean. The surveyor observed on the resident's tray table a sixteen-ounce disposable water cup with a lid and straw and an additional four-ounces of water in a plastic cup. On 3/27/23 at 11:08 AM, the surveyor interviewed the RN who stated Resident #80 went to dialysis on Mondays, Wednesdays, and Fridays at 11:00 AM. The RN continued that the resident usually received a turkey sandwich at 10:00 AM prior to leaving, and they received their sandwich. The RN stated the resident was on a fluid restriction diet and could only drink the fluids provided on their meal trays from dietary as well as 120 mL per shift from nursing. The RN stated that the resident did not ask for additional fluids; he/she drank only the fluids provided. The RN stated residents on fluid restrictions should not have a disposable water cups in their rooms. At this time, the RN accompanied the surveyor to the resident's room and confirmed the resident had a sixteen-ounce disposable cup of water and four-ounces of additional water in a plastic cup. The RN confirmed the resident should not have these fluids, and he removed the lid from the water cup and confirmed there was sixteen-ounces of water in the cup. On 3/27/23 at 11:34 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated residents' water cups were changed daily during the 11:00 PM to 7:00 AM shift. The cups were filled each shift by the aide and if a resident asked for additional water, staff provided. The surveyor asked how staff would know if a resident was on a fluid restriction, and the UM/LPN stated that nurses were aware through the physician's orders and CNAs were aware through the Kardex which included resident care. The UM/LPN stated she was aware Resident #80 received a sixteen-ounce disposable cup of water today and should not have because the resident was on a fluid restriction. The surveyor informed the UM/LPN that they observed a water cup on 3/20/23 and 3/21/23 as well. At this time, the surveyor requested a copy of Resident #80's Kardex. On 3/27/23 at 11:42 AM, the surveyor interviewed the Director of Nursing (DON) who stated CNAs knew a resident was on fluid restrictions by the Kardex and nurses were aware by the physician's order. The DON confirmed residents on fluid restrictions did not receive sixteen-ounce disposable cups of water by the CNAs, unless the nurse put the appropriate amount ordered for that shift in the cup. At this time, the surveyor informed the DON about the observations of the sixteen-ounce disposable water cup on 3/20/23, 3/21/23, and today made by the surveyor; as well as the RN confirmed the cup contained sixteen-ounces of water today. A review of the resident's Kardex dated as of 3/27/23, included for eating/nutrition the resident was on a fluid restriction. On 3/29/23 at 10:50 AM, the surveyor interviewed the Registered Dietitian (RD) who stated the resident started dialysis in hospital prior to being admitted to the facility. The resident went for dialysis treatments three days a week, and she was in communication with the dialysis facility's dietitian. The RD stated that the resident was on a fluid restriction diet. On 3/30/23 at 10:02 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team acknowledged the resident was on a fluid restriction and all staff should have been aware not to give additional fluids. 2. On 3/21/23 at 12:18 PM, the surveyor observed Resident #35 eating lunch in their room with a visitor present. The resident stated he/she received dialysis treatments on Tuesdays, Thursdays, and Saturdays, and they had received dialysis at 5:30 AM this morning. The surveyor observed on the resident's tray 4 oz cranberry juice, an 8 oz mug of tea, a sixteen-ounce disposable cup of water with a lid and straw, and the resident was drinking from a sixteen-ounce paper coffee cup with a lid and straw. The surveyor asked the resident what they were drinking, and they stated tea from home. The surveyor asked if they had to limit fluids because of the dialysis treatments, and the resident stated no. The surveyor reviewed the medical record for Resident #35. A review of the Admission Record face sheet reflected the resident was admitted to the facility in February of 2023 with diagnoses which included chronic obstructive pulmonary disease, chronic respiratory failure, essential hypertension, end stage renal disease, and dependence on renal dialysis. A review of the admission MDS dated [DATE], reflected the resident had a BIMS score of a 14 out 15, which indicated a fully intact cognition. A further review reflected the resident received dialysis treatments while a resident at the facility. A review of the Order Summary Report reflected a PO dated 2/13/23 for fluid restriction diet. An additional PO dated 2/13/23, reflected a 1200 mL fluid restriction (900 mL dietary and 300 mL nursing) with breakfast 6 oz tea and 4 oz milk; lunch 4 oz sugar free juice; dinner 6 oz tea and 4 oz sugar free juice; and nursing 100 mL each shift. A review of the corresponding March 2023 MAR, reflected on the day shift for 3/21/23, the resident received 100 mL of fluids, which did not reflect the sixteen-ounce disposable water cup the surveyor observed. A review of the resident's individualized person-centered care plan included a focus area initiated 2/11/23, that I have nutritional problem or potential nutritional problem with regards to obesity with a body mass index greater than 40; end stage renal disease on dialysis, diabetes mellitus, and congestive heart failure. Interventions included to provide 1200 mL fluid restriction (900 ml dietary and 300 mL nursing); and I have dialysis three times a week; Tuesdays, Thursdays, and Saturdays. I will have a snack prior to leaving and lunch when I return. On 3/27/23 at 11:17 AM, the surveyor interviewed the resident's LPN who stated CNAs were aware of fluid restrictions because the nurses informed them as well as the dietary meal tickets indicated it. The LPN continued the nurses were aware from the physician's orders. The LPN stated residents on a fluid restriction did not receive the sixteen-ounce disposable cups of water each shift and only the nurse and dietary staff could provide the resident with fluids. The LPN confirmed the resident was on a fluid restriction of 1200 mL per day, and the resident could be forgetful, but they were compliant with their restrictions. At this time, the LPN accompanied the surveyor into the resident's room and observed the resident with a sixteen-ounce disposable cup of water with the resident's name and today's date as well as a sixteen-ounce paper cup of tea the resident's visitor brought. The LPN informed the resident they were on a fluid restriction, and they would have to measure out the tea for them. The LPN also removed the sixteen-ounce disposable water cup and removed the lid and confirmed the cup was filled with water. On 3/27/23 at 11:29 AM, the surveyor interviewed CNA #2 who confirmed she was typically assigned to Resident #35. CNA #2 continued that the 7:00 AM to 3:00 PM shift gave residents fresh water daily in their disposable cup. CNA #2 stated she had no residents currently on any fluid restrictions, and confirmed Resident #35 was on no dietary restrictions including a fluid restriction. On 3/27/23 at 11:34 AM, the surveyor interviewed the UM/LPN who stated residents' water cups were changed daily during the 11:00 PM to 7:00 AM shift. The cups were filled each shift by the aide and if a resident asked for additional water, staff provided. The surveyor asked how staff would know if a resident was on a fluid restriction, and the UM/LPN stated that nurses were aware through the physician's orders and CNAs were aware through the Kardex which included resident care. The UM/LPN stated she was aware Resident #35 received a sixteen-ounce disposable cup of water today and should not have because the resident was on a fluid restriction. The surveyor informed the UM/LPN that they observed a water cup on 3/21/23 as well. At this time, the surveyor requested a copy of Resident #35's Kardex. On 3/27/23 at 11:42 AM, the surveyor interviewed the DON who stated CNAs knew a resident was on fluid restrictions by the Kardex and nurses were aware by the physician's order. The DON confirmed residents on fluid restrictions did not receive sixteen-ounce disposable cups of water by the CNAs, unless the nurse put the appropriate amount ordered for that shift in the cup. At this time, the surveyor informed the DON about the observations of the sixteen-ounce disposable water cup on 3/21/23 and today made by the surveyor; as well as the LPN confirmed the cup contained sixteen-ounces of water today. The surveyor requested a copy of Resident #35's Kardex. A review of the resident's Kardex dated as of 3/27/23, included for eating/nutrition the resident was on a fluid restriction. On 3/29/23 at 10:36 AM, the surveyor interviewed the RD who stated the resident received dialysis treatments prior to admission to the facility as well as currently at the facility. The RD stated when the resident was first admitted to the facility, they had edema (excess fluid trapped in the body's tissues), but the fluid had since subsided. The RD stated that she had been in contact with the Dialysis Center RD who was familiar with the resident prior to admission to the facility, and the resident had returned to their usual body weight from six months ago. The RD stated that the resident was on a fluid restriction diet. On 3/30/23 at 10:02 AM, the DON in the presence of the LNHA and survey team acknowledged the resident was on a fluid restriction and all staff should have been aware not to give additional fluids. A review of the facility's Encouraging and Restricting Fluids policy dated updated 1/2023, included the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Verify that there is a physician's order for this procedure .follow specific instructions concerning fluid intake or restrictions. Be accurate when recording fluid intake .when a resident has been placed on fluid restrictions, remove the water pitcher and cup from the room . NJAC 8:39-27.1(a)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to a.) maintain 2 of 2 kitchen hand washing sinks with accessible paper towels; b.) maintain multi-use food-contact surface resident entree plates in a manner to prevent microbial growth; and c.) maintain potentially hazardous food temperatures above 135 degrees Fahrenheit. This deficient practice was evidenced by the following: On 3/27/23 at 7:00 AM, the surveyor conducted a follow-up survey in the kitchen. At this time, the surveyor entered the kitchen and proceeded to wash their hands in the hand washing sink. After the surveyor washed their hands, they attempted to dry their hands but observed the paper towel dispenser was empty. The surveyor asked the four kitchen staff present; the Cook, Dietary Aide (DA #1), DA #2, and DA #3, how the surveyor should dry their hands since there were no paper towels; all four staff responded they needed to retrieve paper towels from the housekeeping department. The surveyor then asked in the meantime how they should dry their hands or if there was a secondary hand washing sink, and the surveyor was directed to an additional hand washing sink in the cook area. The surveyor observed there were paper towels in the dispenser, but the dispenser was jammed, and no paper towels could be removed. At this time, the surveyor interviewed the four kitchen staff and was told the following: An interview with the Cook revealed she arrived at the facility around 5:30/6:00 AM, and she washed her hands in the cook area hand sink. An interview with DA #1 revealed he arrived at the facility around 6:15 AM, and noticed there were no paper towels in the kitchen, so he washed his hands in the bathroom and then returned to the kitchen. An interview with DA #2 revealed he arrived at the facility around 5:30 AM, and washed their hands in the bathroom since there were no paper towels and then returned to the kitchen. An interview with DA #3 revealed he arrived at the facility around 6:45 AM, and he washed his hands in the kitchen and used a napkin to dry his hands since there were no paper towels. Interviews with staff revealed they were all aware there were no paper towels at the hand washing sink. On 3/27/23 at 7:12 AM, the surveyor observed the Cook calibrate a digital thin probe thermometer in an ice bath to 32 degrees Fahrenheit (F). The Cook then proceeded to obtain the temperatures of the breakfast tray line food items and the following food items were held below 135 F: A half pan deep of oatmeal being held directly on the countertop and not held in the steam table was 122 F. Twelve portioned oatmeals in insulated containers with lids being held directly on the countertop and not in contact with a heating element were 125 F. At this time, the Cook stated DA #1 was new to the facility and portioned the oatmeal, but he portioned too many oatmeals to start. The Cook did not reheat the oatmeal to a higher temperature and observed the kitchen serve the oatmeals. On 3/27/23 at 7:30 AM, the surveyor observed a stack of six resident entree plates placed on the breakfast tray line. The surveyor observed four of those plates to have large chips located on the rim of the plates which removed the ceramic coating exposing the plate's porous surface. At this time, the Cook acknowledged the chips in the plates and discard them. The Cook then instructed DA #1 to inspect all the plates from the plate warmer prior to placing the plates on the breakfast tray line for service. DA #1 removed an additional seventy-six entree plates that were all chipped on the rim which removed the ceramic coating exposing the porous surface. On 3/27/23 at 7:38 AM, the surveyor interviewed the Regional Dietary Director (RDD) who was now present in the kitchen. The RDD confirmed the facility should not be using chipped plates because shards of ceramic from the chip could go in the food; someone could cut their hand; and bacteria could harbor in the exposed porous surface. The RDD acknowledged it was a safety concern. On 3/27/23 at 7:38 AM, the surveyor reviewed the temperatures of the portioned oatmeal and the deep half pan of oatmeal being held on the tray line counter not on a heat source. The RDD stated hot foods should be held in the kitchen at 140 F or higher. On 3/27/23 at 9:00 AM, the surveyor interviewed the RDD who stated staff should wash their hands whenever they enter the kitchen area and after changing their gloves. The RDD stated staff were expected to change their gloves anytime leaving the kitchen or changing a task and wash their hands frequently. The RDD stated there were two hand washing sinks in the kitchen that were expected to have paper towels in the dispensers, and staff should have immediately restocked the dispenser when it was noticed there were no paper towels. On 3/27/23 at 10:15 AM, the RDD informed the surveyor that the facility did not have a policy for maintaining kitchen equipment like entree plates, but he stated entree plates were included on a kitchen checklist and plates with chips should not be used. On 3/29/23 at 12:09 PM, the surveyor interviewed the Dietary Director (DD) who stated he was aware of the incident on 3/27/23 with no paper towels in the kitchen, and staff should have immediately replaced the paper towels when it was first realized. On 3/30/23 at 10:02 AM, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) in the presence of the survey team acknowledged the above concerns. A review of the facility's Dining Services Food Temperatures policy dated created 2/7/22, included food will be maintained at the proper temperatures to ensure food safety. The temperatures of hot foods at the point of service (steam table) during tray assembly will be 135 degrees Fahrenheit or above. The cook is responsible to see all food is at proper temperature . A review of the facility's Dinning Service Inc. checklist dated created 2/7/22, included check for cracked trays and check for cracked smallware utensils . A review of facility's Handwashing/Hand Hygiene policy dated revised 1/2022, included hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, ect.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of controlled medication for three residents (Resident #11, Resident #14, and Resident #102). This deficient practice was identified on 1 of 3 medication carts (Applewood Low) reviewed and evidenced by the following: On 3/23/23 at 1:06 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the Applewood Low medication cart. The surveyor and the LPN reviewed the narcotic medication located in the secured and locked narcotic box. When the narcotic medication inventory was compared to the corresponding declining inventory sheet, the surveyor identified the following concerns: Resident #11's pregabalin 50 milligram (mg) tablets, a medication used for neuropathic pain, did not match. The blister pack contained 89 tablets and the declining inventory sheet indicated there should be 90 tablets remaining. Resident #11's clonazepam 0.5 mg tablets (one half tablet 0.25 mg), a medication used for anxiety did not match. The blister pack contained 17 tablets and the declining inventory sheet indicated there should be 18 tablets remaining. The LPN stated she had just administered Resident #11 their pregabalin medication that was scheduled to be given at 2:00 PM and had administered the clonazepam earlier that morning when it was due. Resident #14's lorazepam 0.5 mg tablets, a medication used for anxiety, declining inventory sheet compared with the corresponding blister pack did not match. The blister pack contained 12 tablets and the declining inventory sheet indicated there should be 13 tablets remaining. Resident #102's alprazolam 0.5 mg tablets, a medication used for anxiety, did not match. The blister pack contained nine tablets and the corresponding declining inventory sheet indicated there should be 10 tablets remaining. On 3/23/23 at 1:20 PM, the surveyor interviewed the LPN who stated the declining inventory sheets should be signed before the end of my shift, so the count was correct for the next nurse. The LPN continued that the Medication Administration Record (MAR) was signed after the medication was administered. On 3/23/23 at 1:28 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated the nurse signed the declining inventory sheet at the time they removed the medication from the blister pack. Then the nurse administered the medication and signed the MAR indicating the medication had been administered. The ADON continued the declining inventory sheet was an accountability sheet to account that a medication was removed from inventory because you cannot return a medication back to the blister pack; it must be wasted and destroyed. At that time the surveyor and the ADON together reviewed the declining inventory sheets and the blister packages for the medications identified and the ADON confirmed the LPN should have signed the declining inventory sheets immediately after removing the medications from the blister package, not before the end of their shift as stated by the LPN. On 3/30/23 at 10:07 AM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The DON confirmed the nurse should have signed for the medications as soon as it was removed from the packaging because that was a nursing standard of practice. A review of the facility provided Administering Medications policy dated last updated 1/2023, did not include the facility's process for the use of declining inventory sheets for medication reconciliation. NJAC 8:39- 29.2(d)

COMPLAINT: # NJ 4 Based on interviews, review of Medical Records (MR), and review of pertinent facility documentation on 5/12/2022, it was determined that the facility failed to ensure that their policy on Physician Orders was followed for the Wound Consultant (WC) recommendations for 1 of 4 residents (Resident #1) reviewed for treatment administration. This deficient practice was evidenced by the following: 1. According to the Face Sheet, Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) an assessment tool dated 4/15/2022, showed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14/15, which indicated that the Resident was cognitively intact. The MDS also indicated that the Resident required extensive assistance from staff with Activities of Daily Living (ADL). During a wound care observation of Resident #1's left forearm wound on 5/12/2022 at 11:30 a.m., the Licensed Practical Nurse (LPN #1) stated that the current wound treatment in place on the Treatment Administration Record (TAR) was to cleanse the wound with Normal Saline Solution (NSS), apply [MEDICATION(S)], Calcium Alginate and cover with a clean dry dressing daily. The surveyor reviewed the TAR for the month of April 2022 and May 2022 to verify the order dated 4/4/2022 to cleanse left forearm with NSS, apply [MEDICATION(S)], Calcium Alginate and cover with a clean dry dressing daily. A review of the Wound Care Consultation (WCC) documentation for the month of April 2022 and May 2022 revealed that the Resident's wound on the left forearm was not healed; however, improving. The Nurse Practitioner's (NP) recommendations to the left forearm wound as follows: On 4/27/2022 showed: discontinue prior treatment Apply skin protectant wipes (Skin Prep) to the wound and surrounding skin daily. Cover with abdominal pad and change dressing daily and when soiled. On 5/4/2022 showed: discontinue prior treatments. Cleanse wound with NSS, pat dry, apply double layer [MEDICATION(S)] to the wound, cover with abdominal pad, change dressing daily and when soiled. A review of the Physician Order Sheet, Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, the Resident's MR showed no documented evidence that the Primary Physician (PP) was notified of the NP's aforementioned recommendations. During an interview on 5/12/2022, at 12:10 p.m., the DON stated that the facility would receive the NP's written recommendations the day after the visit. However, it is the responsibility of the Unit Manager (UM) to call the PP and review the changes and get the physician's approval for the order. During an interview on 5/12/2022 at 12:48 p.m., the UM unable to explain why the aforementioned NP's recommendations were not implemented for Resident #1. The UM explained that if wound treatments that are recommended by the WCC were not followed the wounds could get worse. A review of the facility policy titled Physician Orders, dated 3/2022, under Consultant Recommendations/Orders, revealed the following: Consultants may write orders for medication or treatments. In all cases, the attending physician must be notified of the order and approve per state regulations. The nurse will notify the attending physician of findings and recommendations. The attending physician, if in agreement, will order the specific treatments as outlined by the consultant . NJAC 8:39-11.2(b) NJAC 8:39-27.1(b)

Based on observation, interview, and record review, it was determined the facility staff failed to accurately document the administration of a controlled substance medication for two residents, Resident #82 and Resident #75. This deficient practice was identified for 1 of 3 nurses and 1 of 3 carts, reviewed during the completion of the Medication Storage and Labeling task, and evidenced by the following: On 5/05/21 at 9:00 AM, the surveyor, in the Licensed Practical Nurse (LPN) presence, inspected the low side medication cart on Applewood Unit. A review of the reconciliation of the medications located in the secured and locked controlled substance box compared to the controlled substance declining inventory sheet revealed Resident #82's [MEDICATION(S)] 0.5 milligrams (mg) tablets, a medication used for anxiety and seizures, did not match. [MEDICATION(S)] is classified as a Schedule IV controlled substance by the Drug Enforcement Agency (DEA). A Schedule IV drug, substance, or chemical is defined as a drug with a low potential for abuse and low risk of dependence, whose use is restricted and accounted for closely. Resident #82's [MEDICATION(S)] blister pack contained #12 tablets, and the declining inventory sheet indicated there should be #13 tablets remaining. The LPN stated he gave the resident their dose earlier that morning and said he should have signed the medication off on the declining inventory sheet, as administered, immediately after the medication was given. On continued inspection of the low side medication cart on the Applewood unit, in the presence of the same LPN, a review of Resident #75's [MEDICATION(S)] 50 mg tablets count, a medication used for moderate to severe pain, did not match the declining inventory sheet count. [MEDICATION(S)] is also classified as a Schedule IV controlled substance by the DEA. Resident #75's [MEDICATION(S)] blister pack contained #16 tablets, and the declining inventory sheet indicated there were #17 remaining. The LPN again stated he administered the dose to the resident earlier that morning. Again, he acknowledged he should have signed the medication off on the declining inventory sheet, as administered, immediately after the medication was given. At 9:14 AM, the surveyor interviewed the Applewood LPN Unit Manager (LPN/UM), who stated the process for administering a controlled substance medication was to sign the declining inventory sheet after you have given the medication as soon as you are done. The LPN/UM further stated the LPN should have given the medication and immediately signed the declining inventory sheet in the controlled substance book. The reason the medications should be signed for immediately was to keep track of the medication given, as well as keep the medication counts correct. On 5/06/21, the survey team met with the facility Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), and the Corporate Regional Nurse. The DON stated that the controlled substance administration process should be as follows: when a controlled substance was administered, the nurse would pop the pill from the packaging and sign for the dose on the declining inventory sheet. The nurse should administer the medication and then return and sign off for the medication on the electronic medication administration record (eMAR). The DON further stated that the LPN should have followed the procedure and signed off on the medication on the declining inventory sheet. On 5/10/21, The DON provided the surveyor with a copy of a policy entitled Documentation of Medication Administration, updated 10/2019. A review of the policy revealed the following: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. NJAC 8:39-29.7(c)

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards of clinical practice with respect to administering medication, in accordance with a physician's prescribed pain level parameters for [MEDICATION(S)] (a medication to treat moderate to severe pain) for 1 of 2 residents reviewed for pain; Resident #3. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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 5/05/21 at 11:29 PM, the surveyor interviewed Resident #3, lying in bed with a blanket pulled up to their chin. The resident stated they had pain in their arm for the last few months, that it was severe and that [MEDICATION(S)] helped to numb the pain. On 05/05/21 at 12:14 PM, the surveyor spoke with Resident #3's primary Licensed Practical Nurse (LPN), who stated the resident was alert and oriented to person, place, and time. The LPN said that the resident has complained about pain and is currently on a pain management regimen with [MEDICATION(S)]. The [MEDICATION(S)] seems to help the resident after 30 minutes, and they will report the medication was effective. On 5/06/21 at 12:42 PM, the surveyor reviewed the Admission Record of Resident #3, which revealed they were admitted to the facility in January 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the active Order Summary Report revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor then reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #3 when their reported pain level was below the prescribed parameter for severe pain of 6-10 on the following days as indicated by a checkmark: Pain Level 2: 3/9/21 (2050) Pain Level 4: 3/29/21 (1257) Pain Level 5: 3/17/21 (1145), 3/18/21 (1240), 3/19/21 (1221), 3/20/21 (1317), 3/22/21 (1230) and (2130), 3/23/21 (1215), 3/24/21 (1253), 3/27/21 (1226), 3/28/21 (1246). MAR for period 4/1/21-4/30/21 revealed the medication [MEDICATION(S)] was administered to Resident #3 when their reported pain level was below the prescribed parameter for severe pain of 6-10 on the following days as indicated by a checkmark: Pain Level 1: 4/18/21 (2303) Pain Level 2: 4/2/21 (2318) Pain Level 3: 4/2/21 (1500), 4/13/21 (0419), 4/18/21 (0000), 4/27/21 (0407), 4/30/21 (2123) Pain Level 4: 4/10/21 (0425), 4/18/21 (0926) Pain Level 5: 4/5/21 (1134), 4/7/21 (0933), 4/10/21 (1737), 4/14/21 (090 0), 4/26/21 (0819) On 5/10/21 at 9:36 AM, the surveyor observed Resident #3 lying in bed with their blanket pulled up to their chin, with just their bare feet exposed. The resident stated they were uncomfortable and that their pain was currently a seven or an eight out of ten on the pain scale. The resident also said, at times, they get a pain that shoots out of their fingertips, and it can be hard to stop the pain. Resident #3 was assessed and medicated with [MEDICATION(S)] per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/10/21 at 11:40 AM, the DON provided the surveyor with a copy of a policy entitled Documentation of Medication Administration, updated 10/2019. A review of the policy revealed: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Administration of medication must be documented immediately after (never before) it is given. During this same time, the DON provided the surveyor with a copy of a facility policy entitled Pain -Clinical Protocol, updated 10/2019. A review of the policy revealed: 3. The staff and physician will identify the characteristics of pain, such as location, intensity, frequency, pattern, and severity. a. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. On 5/11/21 at 11:30 AM, the survey team met with the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), and the Assistant Licensed Practical Nurse (ALPN). Upon review of Resident #3's March and April electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . After a review of the resident's order for [MEDICATION(S)], the (DON) stated that the [MEDICATION(S)] should only be given if the resident reports a pain level of six or more. The resident should not have received the [MEDICATION(S)] on the acknowledged days, where the pain score reported was less than six. The DON acknowledged there were 14 times in April and 12 times in March where the resident received [MEDICATION(S)] outside the parameters outlined in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] NJAC 8:39-11.2(b)

Complaint # NJ 3 Based on interviews, review of medical records (MR) and other facility documentation, it was determined that the facility staff failed to conduct a timely and thorough investigation according to the facility policy for 1 of 3 sampled residents (Resident #3), who resided on a secured unit, was at risk for elopement and eloped from the facility. On 3/9/2018 Resident (Res) #3 was found outside of the facility building at approximately 2:30 p.m. by a 3-11 shift staff member, Certified Nurses Aide (CNA) #5. The resident was returned to the secure unit by CNA #5 and 7-3 shift Licensed Practical Nurse (LPN) #3 approximetely 10-15 minutes (mins.) later. Although the elopement was immediately reported to the Administrator and the 7-3 shift Unit Manager Licensed Practical Nurse (UM LPN) #1, an investigation was not initiated until 7 days later, 3/14/18. In addition, in-services for facility staff on elopement did not begin until 4/19/2018, day 2 of survey. The facilities' failure to immediately initiate an investigation on 3/9/18, after Res #3 was found outside the building, resulted in an Immediate Jeopardy (IJ) for Resident #3 and 2 sampled (Resident #1 and #2) and 11 unsampled residents who were assessed as being at risk for elopement on the secured unit. The IJ to resident's health and well-being began on 3/9/2018 after Resident #3 exited the building unaccompanied by staff, and the elopement was reported to the Administrator and UM LPN #1 and continued until 4/19/18 when facility wide in-services were conducted in elopement protocol. The IJ was identified by the surveyors on 04/19/18, day 2 of the survey and relayed to the Administrator on 04/19/18 at 1:05 p.m. A Plan of Correction (P[NAME]) was accepted on 04/19/18 at 3:25 p.m. when in-services for all staff on the facility's elopement policy were initiated. 1.) According to an Admission Record, Res #3 was admitted to the facility in 9/2017 with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS), an assessment tool, dated 3/27/18 indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated severe cognitive impairment, ambulated independently and had hallucinations and disruptive behaviors. A review of an Elopement Risk Assessment, dated 12/15/17, revealed that Resident #3 was a high risk for wandering. A review of Resident #3's care plan (CP) included a Focus for elopement risk and wandering with exit seeking behavior, initiated on 10/12/2017 when the resident had exited the building unsupervised. The Goal was to maintain safety and not have the resident leave the facility unattended. Interventions initiated on 10/12/2017 included but were not limited to; distract from wandering, document all incidents of wandering and ensure all staff are aware of elopement risk. Additionally, the CP included that on 3/9/2018 the resident was found by employee entrance . Interventions, dated 3/16/2018, 7 days after the elopement occurred, included but were not limited to; monitor the resident's whereabouts on unit very frequently and offer access to the secure courtyard for walks. Review of the resident's electronic MR (EMR) Progress Notes (PN) revealed a Behavior Note (BN) dated, 3/9/18 at 3:19 p.m. by 7-3 shift UM LPN #1, which included; Resident wandering through out unit today and verbalizing, I am looking for the man, the train and the tickets. Resident required redirection on several occasions. Resident required 1:1 supervision. Frequent Q (every) 30 minute checks to be rendered Q (every) shift. (Family Member) came over from her Jefferson Unit to visit around 3pm and plans of staying for dinner. Further review of the PNs included a Late Entry BN, dated 3/9/18 by UM LPN #1 included the following, It was brought to this nurses attention that resident (#3) had left the building for a very brief period of time and was brought back to his secure unit on Applewood without injury. Prior to incident it was expressed that resident was noted to be attending activities with live music entertainment in MDR (main dining room) off the unit with (family member). Activities (staff) verbalized that resident was last seen with (family member) in main secured court yard for a cigarette. However, it was also expressed that an oncoming staff member found resident walking very closely to building and grounds. This nurse received information and proceeded to investigate and found resident on his secure Applewood unit with some slight aggressive and agitated behaviors. Resident continued to verbalize that he was looking for, The Man, The Train and The Tickets. Resident is a very poor historian and unable to express any recent current events. Resident was not with (family member) at the time this nurse (UM LPN#1) was able to visualize resident and this nurse called to the Jefferson Unit for (family member) to return to Applewood (secured unit) to continue (family member) visit with (Res #3). (Family member) was a very poor historian as well as related to any previous current events. Resident was maintained on unit and Q (every) 30 minute checks were implemented for the weekend Q (every) shift. During an interview with the surveyor on 4/19/18 at approximately 12:00 p.m., UM LPN #1 confirmed that she wrote the aforementioned BN on 3/14/18. A Facility Reportable Event Record Report (AAS-45), completed by the Administrator and faxed to the NJ DOH on 3/14/2018 included that after a visit from a state agency on 3/14/2018, a 3-11 shift CNA confirmed that she found Resident #3 in the employee parking lot at approximately 2:30 p.m. on 3/9/2018. The CNA walked with the resident around the parking lot for 10-15 minutes because he refused to come in. The CNA called the reception desk to request assistance and staff members redirected the resident back to the building. The AAS-45 included that the UM (UM LPN # 1) of the secured unit was not present on the unit when the incident occurred, however, UM LPN #1 documented that the resident had wandering and agitated behaviors that day and had been redirected several times. She (UM LPN #1) was made aware from the nurse on the unit that the resident was found outside by the employee entrance door and brought inside by a staff member. She did not document at the time but added a late entry today. Because of his behaviors that day and being found outside she did initiate 30-minute checks. She just did not enter the documentation timely. We are conducting an investigation to determine how the resident exited the building, including viewing the security camera tapes. Additional information from the Administrator was faxed to the NJ DOH on 3/19/2018 which included that after investigation, speaking with staff and viewing the video cameras we learned that (Resident #3) went into Room .on the (secured unit) and managed to push open the window screen and kick open one of the door [MEDICATION NAME], letting himself out through the window. He was viewed on the camera at 2:20 p.m.Following the incident he was returned to the facility and assessed .placed on 30 minute visual checks and placed in the common areas for observation. Because he is ambulatory it is difficult to continually supervise him as he does not stay in one spot . The AAS-45 also included that the room window was repaired and all other windows checked to insure they were secured with window stops and screens in place. Additionally, the Responsible Party (RP) and physician were made aware of the elopement on 3/14/18 at 4:09 p.m. Review of the facility investigation/timeline and statements provided by the Administrator on survey, 4/18 and 4/18/2018 included; on 3/9/18 at approximately 2-2:15 p.m., Resident #3 exited the secured unit with other residents accompanied by activity staff, however, instead of going into the main dining room (MDR) he went into the secure smoking courtyard. The resident was returned to the secured unit at approximated 2:20 p.m. During interviews with the surveyors on 4/19/2018 at 10:55 a.m., the Assistant Director of Activities (ADA) stated the resident was always in view of staff when he was in the smoking area until his return to the secured unit. The timeline further indicated that approximately 10 minutes later at 2:30 p.m. on 3/9/2018, Resident #3 was found by the employee entrance by CNA #5, who was reporting to work. CNA #5 notified the receptionist that Resident #3 was outside of the building. The receptionist called the secured unit and notified the 7-3 shift LPN #3 that Resident #3 was outside the building. LPN #3 and CNA #5 returned the resident inside within 5-10 minutes. (LPN #3) later notified the administrator that (Resident #3) was back on the unit, however, the administrator thought she was referring to the incident from the smoking courtyard. Additionally, the 7-3 shift UN LPN #1 was notified that Resident #3 had gotten off the unit. She (UM LPN #1) went to (the secured unit) and saw that he was safely on the unit . The UM LPN #1 discussed the event with the Assistant Director of Nursing (ADON), the staffing coordinator and the ADA. On 3/14/2018, during a visit from a state agency, the Administrator was made aware that Resident #3 had left the unit twice, within a half hour and she had misunderstood the call from (LPN #3). An investigation was immediately begun . The timeline conclusion indicated that the facility looked at security cameras which showed that the resident had gone in a resident room but had not come out. The staff checked the room and noted that safety stops on a window had been broken off and the window screen was missing and staff believed the resident exited the building through the window. All windows were checked that day (3/14/2018). Review of written statements from staff included the following; An Incident/Accident Staff/Resident Witness Statement, from CNA #5, signed and dated 3/9/2018, the day of the elopement, revealed that on 3/9/18 at 2:30 p.m., (CNA#5) was coming for my shift when I saw (Res #3) in the parking lot for employees. (CNA #5) then approach him to redirect (Res #3) back into the building .(CNA #5) called the front desk for assistance. CNA #5 was unable to be interviewed by the surveyor. An Incident/Accident Staff/Resident Witness Statement, dated 4/19/18 (the second day of survey) from LPN #3, revealed she was called by the receptionist that the resident was outside in the parking lot and she responded and assisted the resident along with CNA #5. . My unit manager was not available so I notified the ADM. (administrator). During an interview with the surveyors on 04/19/18 at 11:58 a.m. LPN #3 confirmed her statement and added that she reported the elopement to the ADM because UM LPN #1 is my first chain of command but she was off the unit. LPN #3 stated she usually would complete an incident report (IR), however, the administrator stated; she would take care of it. LPN #3 stated she did not recall if she wrote a PN in the EMR on 3/9/2018. She confirmed she was asked to write a statement on 4/19/2018. Review of the EMR did not reveal any documentation on 3/9/2018 that Resident #3 had eloped. There was no statement provided by the facility for UM LPN #1. During an interview with the surveyor on 4/19/2018 at 9:50 a.m., UM LPN #1 stated that she was working on 3/9/2018 but not on the secured unit. She stated she was asked by the Maintenance Director if she heard that Resident #3 got out and she immediately checked and noted the resident on the unit at approximately 3:00 p.m. She stated she was speaking with the ADON when she was interrupted by the Staffing Coordinator who stated Resident #3 couldn't have gotten off the unit (because) he went to activities. UM LPN #1 stated she thought the reference was to the earlier event when the resident was in the smoking courtyard. UN LPN #1 confirmed she did not follow up with an investigation or any more interviews of staff because she was not informed that he was outside the perimeter of the building. During an interview with the surveyors on 4/18/18 at 12:40 p.m. and 4/19/18 at 1:00 p.m., the ADM confirmed her aforementioned timeline that the elopement occurred on 3/9/18 but the investigation did not begin until 3/14/18. The ADM stated there was a miscommunication of the elopement because the resident was found in the smoking courtyard earlier the same day. Additionally, the ADM stated that she did not receive the written statement, dated 3/9/2018 by CNA #5 until 3/14/2018. They (staff) should have reported it. I should have reported it . The ADM stated that when LPN #3 called her and told her Resident #3 was back in the building, I thought she was talking about him in the courtyard and she said he's fine . The ADM confirmed she obtained LPN #3's statement during survey on 4/19/2018. The surveyor conducted an interview with the ADM on 4/18/18 at 12:40 p.m. who confirmed her aforementioned timeline and stated the elopement occurred on 3/9/18 but the investigation did not begin until 3/14/18. The ADM stated there was a miscommunication of the elopement because the same resident was found in the courtyard, earlier the same day in the smoking courtyard within the facility. I believe the CNA called the front desk for help. I don't know if anyone helped her. No statements from any other staff members received. The staff should have reported it to the nursing supervisor. Additionally, the ADM stated that according to the UM LPN #1, verbal in-services were conducted after 3/14/18, however, she was not sure of the content. During an interview with the surveyors on 4/19/18 at 2:30 p.m., UM LPN #1 stated she in-serviced staff on the elopement policy and reporting, however, did not document it. UM LPN #1 provided an Education Record, dated 3/14/18 which indicated what she reviewed, however, she stated that she wrote this on 4/19/2018, day 2 of survey. There were no employee signatures attached to the document. The surveyor conducted interviews on 4/18/18 and 4/19/18 with CNA #1, CNA #2, CNA #3 and CNA #4, all of who stated they could not recall receiving in-services recently on elopement or reporting. Review of a facility policy, dated; revised 09/08 and titled; Resident Incidents and Accidents, included but was not limited to: It is the policy of this facility to provide a safe and healthful work environment. All incidents or accidents occurring on our premises must be reported to the Director of Nursing and the Administrator. This shall include any unusual events or elopements. Definitions: Incident-Any occurrence that befalls a Resident that Does Not alter his/her physical condition or appearance .This can include any unusual event or elopement . Procedure for Incident and Accident Report: 1. When an incident occurs, the nurse on the unit will examine the resident to determine if it is an accident or incident as per definition. 2. The nurse will then fill out the Resident Accident/Incident report in full . 4. The family or responsible party will be called within (3) hours on all incidents by the respective charge nurse. 5. Physician must be notified of all incidents or accidents. 6. All resident Incident/Accident reports must include the following: A. TPR and BP B. Body check C. Range of Motion D. Neuro check with head injury 7. Nurse completing the investigation will immediately institute necessary interventions to ensure Resident Safety. 8. In addition to #6 above, nurses notes must be written every shift for 72 hours and must include complete vitals and evaluation of resident's status. 11. The Care Plan must be reviewed and updated accordingly with appropriate interventions. 12. Incident/Accident investigation will include pertinent statements before nurse signs form. The Incident/Accident Investigation form will include an interview with the Resident and care givers, and will be signed by the nurse, DON designee. 13. Completed form will be forwarded to DON for evaluation/conclusion. 14. DON will forward investigation form to Administrator for signature and to the Medical Director for signature. The completed Incident/Accident Investigational Report is then attached to the completed Incident/Accident Report and sent to the Nursing Office for review and filed with reports . Review of a facility policy, dated revised, 11/01/10 and titled; Wandering/Elopement Policy, included but was not limited to: .Procedure: . 6. In the event of elopement, the Missing Resident Policy and Procedure must be followed. 7. Care plan must be reviewed on every elopement attempt. 8. Resident identified as high risk for elopement will be reviewed during care conference by the Interdisciplinary Care Team to review and revise plan of care. 9. At Risk for Elopement care plan must be maintained until the resident is no longer considered a high risk for elopement. 10. All resident elopements must be investigated and reported to proper agencies. Review of a facility policy, date revised; 6/16/09 and titled Patient Safety Search for Missing Residents (Code Gray), included but was not limited to: .Procedure: .Resident return to the facility: Upon return to the facility, the resident will be assessed and care will be provided appropriately based on the conditions/situation. The IJ began on 03/09/2018 when Resident #3 eloped from the facility and an investigation was not immediately initiated. The IJ was identified by the surveyors on 04/19/18 and the Administrator was notified on 04/19/18 at 1:05 p.m. The IJ continued until an acceptable P[NAME] was received by the surveyor at 3:25 p.m. with the initiation of in servicing staff. The P[NAME] submitted stated the following: 1. There was one resident involved in the deficient practice Resident #3, who resides on a secured memory unit (Applewood). Resident #3 was returned to Applewood without incident. Resident #3 is now bedbound on hospice and no longer an elopement risk. 2. All residents are potentially at risk following an incident that is not investigated timely. 3. The staff on the Applewood Unit were educated by the unit manager on 3/14/18 regarding the proper procedure to follow when a resident elopes, and the appropriate communication process that needs to occur to ensure timely investigation. Education began for all staff on 4/19/18, which includes timely reporting of incidents to a s supervisor to ensure investigations are initiated in a timely fashion. Education of all staff will continue and be completed by 4/23/18. Elopement education and timely communication are included at new hire orientation, and annually. Staff on the Applewood unit will also receive this education quarterly for the next 12 months. Staff who are not scheduled between now and 4/23/18 will be mailed the education to review, and then sign off on the next time they are in the building. 4. Audits will be performed on each unit weekly for 90 days for all resident incidents to ensure investigations are initiated timely, and in accordance with company policy. These audits will be conducted by the DON or her designee and reported quarterly to the Quality Assurance Committee. Completion Date 04/23/18 NJAC: 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to implement nutritional interventions and/or monitor weights to prevent weight loss. This resulted in an avoidable, significant weight loss of 19 lbs in two months for Resident #11, and a weight loss of 10 lbs in 20 days for Resident #8. This deficient practice was identified for 2 of 17 residents reviewed for weight, and was evidenced by the following: 1. During the initial tour on 3/13/17 at 7:45 a.m., the Licensed Practical Nurse Unit Manager (UM) told the surveyor that Resident #11 was confused, had a poor appetite and had experienced weight loss since admission. The surveyor observed Resident #11 to be thin, standing near his/her bed as the UM assisted the resident to lay back down. On 3/13/17 at 11:55 a.m., the surveyor observed Resident #11 during the lunch meal. The resident's tray consisted of a fish filet, rice, string beans, 4 ounces (oz) of whole milk and a small slice of angel food cake. The surveyor observed the resident eat a forkful of rice before calling out, Can I have some ice cream? At 12:05 p.m., a unit nurse asked the UM to specify whether ice cream or magic cups (a nutritional dessert with substantially higher calories and protein than ice cream) should be requested from the kitchen. The UM responded ice cream. At 12:20 p.m., a 4 oz container of ice cream was given to Resident #11 who consumed 100% of it. On 3/15/17, the surveyor reviewed the medical record for Resident #11 who was admitted to the facility on [DATE]. The Admission Nutrition Assessment and Plan of Care dated 1/10/17 indicated that Resident #11 weighed 127 lbs, Feeds self, Appetite and po (by mouth) intake variable, and Weekly wts (weights) in place. The Comprehensive Care Plan (CCP) for Significant Weight Loss x (times) 1 month initiated on 2/14/17 (one month after admission) indicated to initiate super cereal at breakfast and ice cream + (plus) dessert at L (lunch) and D (dinner). Weekly weights x 4 weeks were also ordered. A revision of the CCP for Resident #11's significant weight loss, dated on 3/9/17 (two months after admission) indicated a dietary recommendation to discontinue ice cream and dessert with lunch and dinner, and change to magic cup and dessert with lunch and dinner. On 3/15/17 at 11:40 a.m., the surveyor observed Resident #11's lunch tray delivered to the resident's room. It contained meatball goulash, 4 oz of whole milk, a fruit cocktail dessert and a small container of vanilla ice cream. The resident was drinking the milk. The diet slip on the tray indicated 4 oz. Ice Cream. During an interview on 3/15/17 at 1 p.m., the Registered Dietician (RD) stated that she needed to review Resident #11's electronic medical record (EMR) in order to speak to the resident's weight loss. During the review of the EMR, in the presence of the surveyor, the RD reviewed Resident #11's Weight Summary. The summary included three weights since admission as follows: 1/6/17 127.0 lbs 2/7/17 119.0 lbs 3/7/17 108.6 lbs The RD stated that Resident #11's significant weight loss in one month was not identified until 2/14 when a diet alert was received from the UM that Resident #11 had a significant weight loss of eight pounds (6.3%) in one month. Super cereal at breakfast and ice cream plus dessert was initiated on 2/14/17. In addition, the RD stated that weekly weights x four weeks were recommended again. Review of the Treatment Administration Record (TAR) indicated that weekly weights were not done for Resident #11 as ordered for both January 2017 in accordance with the facility's admission weight protocol, and for February 2017 following the dietitian's updated recommendations on 2/14/17. The RD could not explain why the weekly weights were not obtained and monitored in January and February; or why seven days passed after the February weight was known for additional interventions to be implemented for further weight loss prevention. The RD further stated that on 3/9/17, a second diet alert was received from the UM that Resident #11 had again lost a significant amount of weight over one month, which equaled a total loss of 14.5% in two months, and a recommendation was made to change the ice cream with lunch and dinner to magic cup. The RD told the surveyor that magic cups have 290 calories and 9 Grams of protein, making it a better choice for Resident #11. The RD could not explain why Resident #11 was not receiving the magic cup as recommended. There was no documented evidence that actual caloric intake and/or laboratory values were monitored for Resident #11 since admission. During an interview on 3/15/17 at 1:20 p.m., the UM and unit nurse acknowledged that weekly weights were not done for Resident #11 in January and February as ordered. No further explanation was provided. On 3/15/17 at 1:30 p.m., the surveyor interviewed the Food Service Director (FSD) who stated that a recommendation for magic cup with lunch and dinner was never received for Resident #11 so the kitchen continued to deliver the ice cream. On 3/17/17 at 12:10 p.m., the Administrator stated that Resident #11 should have had weekly weights monitored on admission, however, the resident was transferred from another unit and the order didn't appear on the TAR. As a result, the weights were not done. The Administrator acknowledged that the facility staff was unaware that the weights were not done. During the same interview, the Administrator stated that a Physician order [REDACTED]. According to the Administrator, the PO was revised on 2/22/17 and the nurse made an electronic error which failed to trigger for weights to be monitored for Resident #11 in February. The Administrator further stated that the RD's recommendation on 3/9/17 for Resident #11 to receive Magic Cups instead of ice cream was missed by the nursing staff. Review of a PO dated 3/15/17 indicated magic cup at lunch and dinner. During an interview on 3/21/17 at approximately 9:45 a.m., the Administrator stated, We've identified some breakdowns in the system, some inconsistencies. 2. On 3/13/17 at 8:30 a.m. during the initial tour, the surveyor observed Resident #8 in bed with the eyes closed. The UM told the surveyor that the resident had a recent weight loss due to a decline in appetite. On the same day at 9:13 a.m. during the medication pass observation, the surveyor observed Resident #8 in bed. The resident had a thin, frail appearance. The Licensed Practical Nurse (LPN) stated to the surveyor that the resident needed to drink because he/she was not eating much. After the LPN administered the medications, the resident requested for some juice. The LPN provided orange juice to the resident. On 3/15/17 at 4:00 p.m., the surveyor reviewed the medical record for Resident #8 who was hosptalized on [DATE] and readmitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of the resident #8's Weights and Vitals Summary revealed the following: 1/5/17 113 lbs 2/7/17 106.2 lbs (upon readmission to the facility) 2/13/17 108.6 lbs. Review of the Readmission Nutrition Assessment and Plan of Care screen dated 2/16/17 and timed at 2:40 p.m. reflected that the resident had a 7 lb (6%) significant weight loss following a six-day hospitalization . The RD summary and recommendations revealed that the resident had no history of [MEDICAL CONDITIONS] (a medical condition that can affect fluid volume). In addition, the RD noted that the resident was readmitted with a diet order for a 2-3 gm sodium diet. The RD recommended to change the diet to a no added salt (NAS) diet, resume super cereal with breakfast, and add 120 ml of 2 Cal HN (a high calorie nutritional supplement) four times per day with medications, in order to supplement diet and assist with weight increase. A review of the Dietitian's Recommendations communication sheet dated 2/16/17 indicated the same: change diet to regular NAS, resume super cereal at breakfast and 120 ml of 2 Cal HN QID with meds - record % (percent) consumed. There was no evidence within the medical record that the dietary recommendations had been implemented or addressed by the physician on 2/16/17. Further review of the resident's Weights and Vitals Summary indicated that a weight was not obtained from 2/16 until 2/27, and revealed the following: 2/27/17 96.2 lbs (a 10 lb weight loss over a period of 20 days) Review of a Dietary Note dated 2/28/17 and timed for 11:23 a.m., revealed that the RD received a dietary alert related to a significant weight loss x 2 weeks with poor oral intake. The Dietary Note read that the order for the 2 - 3 gram sodium diet continues. In addition, the RD noted that the dietary recommendations had not yet been implemented. Review of the Dietician's Recommendations communication sheet dated 2/28/17 repeated the recommendation from 2/16/17. The RD wrote, re-recommend from 2/16/17- super cereal with breakfast, 120 ml of 2 Cal HN QID with meds, change diet to regular NAS, discontinue 2-3 gm sodium diet. Review of the electronic Medication Administration Record [REDACTED] On 3/17/17 at 9:45 a.m., the surveyor interviewed the RD. The RD confirmed that Resident #8 was nutritionally assessed on 2/16/17 upon readmission to the facility, and that the dietary recommendations she made on that date were not carried through for a period of 12-days. The RD stated that she was unaware the recommendations had not been implemented until she received a dietary alert on 2/28/17 that the resident had lost an additional 10 lbs since readmission. At that time the RD stated to the surveyor that upon completion of the Dietician's Recommendations communication sheet, several copies get made and distributed to the Administrator, Assistant Administrator, Director of Nursing (DON), Minimum Data Set (MDS) Coordinator, and the UM. The RD stated that the UM was responsible to call the physician for any dietary recommendations made. The RD confirmed there was no evidence it had not been done on 2/16/17. On 3/20/17 at 12:42 p.m., the surveyor interviewed the DON in the presence of the survey team. The DON stated, there was a delay in implementing the RD's recommendations on 2/16/17. The DON acknowledged the 12-day delay before dietary recommendations were followed for Resident #8 who experienced a significant weight loss. (Refer to F282) NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to implement interventions identified in the Comprehensive Care Plan to monitor and prevent further weight loss for Resident #11 who had significant and avoidable weight loss, and Resident #8. This deficient practice was identified for 2 of 23 residents reviewed for care plan implementation and was evidenced by the following: 1. Resident #11 was admitted to the facility on [DATE]. Review of the resident's Admission Nutrition Assessment and Plan of Care indicated an initial weight of 127 lbs. The surveyor reviewed the resident Weight Summary that reflected a 2/7/17 weight of 119 pounds (a 9 pound weight loss in 1 month.) Review of a Comprehensive Care Plan (CCP) initiated on 2/14/17 indicated that Resident #11 had a Significant weight loss x 1 month. The identified Goal was to maintain the resident's weight between 117-127 lbs. Interventions identified to monitor and prevent further weight loss included the following: 1. Weekly weights x 4 weeks dated 2/14/17; 2. Monitor weight and labs and po (by mouth) intakes dated 2/14/17; and 3. magic cup and dessert with lunch and dinner dated 3/9/17. Review of the Treatment Administration Record for February indicated that weekly weights were not done after the resident's significant weight loss. During an interview on 3/17/17 at 12:10 p.m., the Administrator stated that no laboratory tests had been ordered for Resident #11 since admission two months ago, and there was no documented evidence of monitoring actual caloric intake for Resident #11. On 3/13/17 at 11:55 a.m. and on 3/15/17 at 11:40 a.m., the surveyor observed that Resident #11 did not receive magic cup nutritional desserts as indicated in the CCP. The surveyor reviewed the resident's Weight Summary that reflected the resident weighed 108.6 pounds on 3/7/17, a weight loss of 10.4 pounds in 1 month, and a total of 18.4 pounds in 2 months. There was no documented evidence that the facility obtained weekly weights for 2 months; monitored by mouth intake on a consistent basis; and failed to provide the nutritional dessert supplement as recommended by the dietitian from 3/9 to 3/15/17. 2. On 3/15/17 at 4 p.m., the surveyor reviewed the medical record for Resident #8 who was readmitted to the facility on [DATE] with a weight of 106.2 lbs. The Readmission Nutrition Assessment and Plan of Care dated 2/16/17 indicated that Resident #8 had a significant weight loss of 7 lbs following a hospitalization . A review of the resident's CCP reflected that Resident #8 had a compromised oral intake and a history of weight loss. The identified Goal was to increase and stabilize the resident's weight between 120 - 130 lbs. The goal was revised on 2/13/17. The care plan included the following interventions: 1. Provide and serve the diet as ordered and monitor intake and record every meal initiated 7/6/16. 2. Super cereal with breakfast revised 2/28/17. A review of the Health Status Notes (HSN) following readmission indicated no nursing progress notes dated between 2/11/17 until 2/17/17 at 11:43 p.m. There was no documented evidence within the medical record that a meal intake was monitored until 2/18/17 at 9:39 a.m. The HSN at that time reflected that the resident consumed 0% of breakfast and 10% of lunch. On 3/17/17 at 8:05 a.m., the surveyor observed Resident #8 in bed. There was a cup of water on the bedside table. The meal delivery truck was outside the resident's room. At that time, the surveyor requested to see the breakfast tray in the presence of the CNA. The CNA stated that the resident refused most of the breakfast, and only ate one bite of the oatmeal and a 4 oz orange juice. The CNA pulled the resident's breakfast tray from the meal delivery truck and the surveyor observed a bowl of oatmeal, two whole waffles that were untouched, one empty 4 oz container of orange juice, and one 8 oz cup of coffee. There was no evidence of super cereal confirmed by the CNA. The CNA stated that she needed to let the nurse know how much the resident ate and that the nurse would then document the meal intake in the computer. On the same day at 8:10 a.m. the UM observed the resident's breakfast tray on the meal delivery truck in the presence of the surveyor. The UM confirmed there was no super cereal on the breakfast tray. At that time, the UM provided a dietary recommendation dated 3/9/17 that indicated to discontinue the super cereal and add 8 oz of juice with every meal. The UM acknowledged that the care plan had not been updated to reflect the new recommendations made on 3/9/17. The meal ticket reflected to give two 4 oz containers of orange juice with breakfast. The UM confirmed she only saw one 4 oz orange juice. On 3/20/17 at 12:40 p.m. the surveyor interviewed the DON in the presence of the survey team who confirmed the super cereal had been discontinued on 3/9/17, and acknowledged the care plan had not been updated to reflect the changes. The DON also stated that staff needed to review the meal ticket to ensure it matched what was being served on the trays. (Refer to F325) NJAC 8:39-11.2(e)2