Every finding on record at Complete Care at Laurelton, LLC

Based on record review, interviews, and review of the facility's policy titled Discharge Planning Process, on 04/21/2026 through 04/23/2026, it was determined that the facility failed to ensure that a resident was discharged to a safe home, including the repair of a water pipe prior to discharge, for 1 of 1 residents (Resident (R) 1) reviewed for appropriate discharge from the facility. As a result, R1 was discharged to an unsafe home without running water or heat. Ten days after discharge, the police were called to the home to find the resident with limited electricity, no running water or working heating system, and unable to walk or get down the stairs, other than sliding down on his/her buttocks. R1 was taken by the Police Department (PD) to the Emergency Department (ED) for care. The facility's failure to ensure a resident was discharged to a safe home posed a likelihood that serious injury, harm, impairment, or death could occur to all discharged residents. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 04/06/26 after R1 was discharged to an unsafe home that lacked running water or heat. On 04/22/26 at 4:30 PM, the Executive Administrator, Administrator, and Director of Nursing (DON) were notified that an Immediate Jeopardy (IJ) was identified for F627 at a Scope and Severity (S/S) of J related to the facility's failure to ensure a resident's safe discharge home. On 04/23/26, the facility provided a Removal Plan that was accepted at 2:15 PM. The surveyor validated the implementation of all components of the removal plan, which included, all known planned discharges have been fully reviewed by the facility Interdisciplinary Team (IDT) to determine safe discharge, Social Worker (SW) was re-educated on 04/22/2026 on Safe Discharge Processes, Documentation, Care Plan Meetings and Adult Protective Services (APS) referral process, inservicing of all nursing staff and IDT team members on safe discharge processes, audits of all discharges for the last 30 days to ensure safe and appropriate discharges. The IJ was removed on 04/23/26 at 6:48 PM. The S/S was lowered to a D, indicating no actual harm with potential for more than minimal harm. Findings include:Review of R1's admission Record (AR) revealed R1 was admitted with medical diagnoses that included schizophrenia unspecified, muscle wasting, and difficulty walking. Review of R1's admission Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 03/12/26, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R1 had moderate cognitive impairment. R1's ability to walk 10 feet was assessed as needing partial/moderate assistance. Review of R1's Care Plan (CP) dated 04/07/2026, revealed under Focus, R1 wishes to return to the community upon discharge. Under Goal, The resident will be able to verbalize/communicate required assistance post-discharge and the services required to meet needs before discharge. Under Interventions, Evaluate and discuss with the resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss, and address limitations, risks, benefits, and needs for maximum independence. Review of R1's hospital psychological consult located in Misc. [Miscellaneous] dated 02/12/26, and uploaded on the date of admission, revealed The condition of the environment R1 came from prior to admission to the inpatient psych facility, documenting that a neighbor called the police due to water running out of the house from a broken water pipe, the utilities were turned off, and the house was in complete disarray, including an infestation of insects. Prior to admission, R1 resided in a hotel due to [the] condition of the house. Screening notes describe the resident was disheveled, malodorous and admitted to not taking a shower in 5 years due to concerns about slipping. During the current psychological evaluation, the resident had no insight regarding their condition or overall deterioration. Review of the Social Services Assessment (SSA) dated 03/14/2026, revealed Presented to the emergency room (ER) on 02/12/2026 after he/she was found living in deplorable conditions at home, by neighbors, after they noticed water leaking from his/her house due to a burst pipe, which [the] patient downplays. Apparently, the patient's utilities had been turned off, and the house was in complete disarray [,] including an infestation of insects were noted. He/she reported that he/she hadn't taken a shower in five years because he/she was afraid of slipping. He/she was transferred to a behavioral health facility secondary to multiple psychiatric conditions. He/she presents there as disorganized, dirty and disheveled. admitted with Delusional Disorder. Patient was medically stabilized and given poor functional status upon discharge, it was felt the patient would continue to benefit from a term of skilled rehab and the resident was transferred to Complete Care at Laurelton for Subacute Rehabilitation (SAR) on 03/06/2026. Resident is now on therapy services for decline in Activities of Daily Living (ADL)s, function, [and] mobility status post (s/p) hospitalization. Rehab potential is fair to good. Review of R1's Progress Note (PN) revealed the discharge note on [the] day of discharge, 04/06/26 at 4:30 PM, documenting Patient discharged [from] facility via cab at 1630 [4:30 PM]. Patient left before signing [the] discharge summary. Writer attempted to contact [the] patient with no response. Patient left with all belongings. All parties were made aware. Review of R1s Discharge Instructions (DI) dated 04/06/26 at 1:00PM, revealed the resident was to be discharged home via ambulette. Under Home Health Services, indicated, Home Health Agency (HHA), Adult Protective Services (APS) will be called for R1's home care. The DI further showed the Heating, Ventilation and Air conditioning (HVAC) company will be on-site for repairs, per the resident, in the next day. The copy of the discharge instructions provided by the facility were not signed by the Nurse or the resident prior to discharge. Review of R1's PN documented on 04/14/26 at 10:07 AM, Social Services Director (SSD) and Administrator spoke regarding discharge and a call was received from [local] Police Department (PD) regarding [R1] safe discharge. [R1] was at this time going to be referred to Mobile Crisis for intervention. PD will call back when [R1] was on [his/her] way to the Emergency Department (ED). SW [Social Worker] will continue to follow as things unfold. During an interview on 04/21/26 at 9:44 AM, the SSD explained that R1 was admitted from an inpatient psych facility, the resident's house had no electricity or water in the home and was admitted to the Memory Care Unit at the facility due to the diagnosis of schizophrenia. The SSD stated that she and the Administrator asked R1 about a plan to fix the water pipe so R1 could be discharged . The SSD explained that the discharge was delayed for R1 to arrange for the repair service to fix the broken water pipe. According to the SSD, she called to APS and spoke with SW2 about following up in the community. The SSD stated R1 was adamant that the house was safe to return home. She recalled that the Director of Nursing (DON) received a call from the local PD stating it was okay for the resident to go home. The SSD stated that she arranged home health care and coordinated ambulance transportation to return R1 back home, and R1 was discharged . The SSD stated a week later there was a call from the PD asking why they discharged R1 home when there was no electricity or running water in the house. The SSD verified that the facility did not follow up to ensure the safety of R1's home, whether he/she had running water or utilities, or whether the environment was considered a safe place to discharge R1. In a second interview on 04/23/26 at 5:30 PM, the SSD stated that an initial 72-hour care conference was done in person and not documented in the Electronic Medical Record (EMR). During an interview on 04/21/26 at 10:30 AM, the DON stated she received a call on her personal phone on 04/01/2026 at 3:47PM from the local PD requesting to speak to R1. The DON stated she took her personal phone to R1, placed it on speaker, and recalled that the PD officer said the building was no longer red taped and that R1 could go home anytime, if the water pipe was fixed. However, review of R1's EMR lacked documentation of the phone conversation between the local PD and the DON. During a phone interview on 04/21/26 at 11:15 AM, SW3, hired by the local PD, explained she went with the PD to R1's residence the house was red tagged by code enforcement. SW3 stated there was a flood due to a burst water pipe. While at the home, SW3 and the PD found R1, who lived upstairs, unable to walk well. SW3 observed R1 unable to walk down the stairs and scooted each step on his/her buttocks to open the door for the PD and SW3 to gain entry to the home. SW3 stated that no phone was available, the food in the home had expired in 2023, and that she was concerned R1 had been discharged to an inappropriate house due to its condition. During an in-person interview at the PD on 04/22/26 at 9:05 AM, the Police Department Captain (PDC) confirmed being aware of R1, and the Community Resource line received many calls for this resident. The PDC stated all officers were familiar with R1 and aware of the need to fix the plumbing, electric and heating systems before the house would be deemed safe to live in. During a phone interview on 04/22/26 at 10:20 AM, the APS SW2 confirmed a conversation with the SSD from the facility discussing the need for a safe discharge for R1. SW2 stated a call to an APS SW was not a referral. The SW confirmed there was no open case for R1 in the system and that there was no follow-up visit by APS to check on R1's welfare once they returned home. During an interview on 04/22/26 at 11:54 AM, the DON and Administrator explained that, generally, a care conference is held within 72 hours of admission to begin the discharge process for short-term residents. The DON stated that after the phone call from the local PD, the DON and Administrator spoke with R1 about fixing the water pipe and R1 was prepared to fix it before going home. R1 informed the facility that the repair company needed someone at the house to complete the repair, and confirmed the repair was to occur on 04/06/26, the day of discharge. The DON and Administrator confirmed that the discharge for R1 was inappropriate and unsafe. The DON believed R1 when he/she told them that they would get the water pipe fixed. The facility did not confirm the water pipe had been repaired prior to discharge. During a phone interview on 04/23/26 at 12:50 PM, the HHA confirmed that the facility made a referral to them for R1, and after reviewing the insurance coverage, the HHA emailed the facility to informed them that they declined the referral and that the facility needed to find a different HHA to provide care to R1. Review of the facility's policy titled, Discharge Planning Process, reviewed/revised 03/01/25, revealed under Policy It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions., under 4) In cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the interdisciplinary team will treat this situation similarly to refusal of care: b) Offer other, more suitable, options or locations that are equipped to meet the needs of the resident. Document any discussions related to the options presented .d) At time of discharge, follow policies regarding discharges Against Medical Advice (AMA), and refer to Adult Protective Services (or other state entity charged with investigating abuse and neglect) as necessary, under 6) An active individualized discharge care plan will address, at a minimum: Discharge destination, with assurances the destination meets the resident's health/safety needs and preferences. and under 12) The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. NJAC 8:39-5.4(b)(c)

NJ Complaint: #NJ186246 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and accepted professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 3 of 3 (Resident #77, 110, ) residents reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #77's quarterly Minimum Data Set (an assessment tool) dated 12/25/2024, revealed that Resident #77 had a brief interview of mental status score of 15 which indicated he/she was cognitively intact. A review Resident # 77's diagnoses located in the Electronic Medical Record (EMR) include but are not limited to Diabetes Mellitus (the body's inability to use insulin properly, leading to high blood sugar levels). A review of Resident #77 physician's orders revealed the following orders but not limited to Insulin Regular Human Injection Solution 100 UNIT/Milliliter (a hormone produced in the pancreas that plays a crucial role in regulating blood sugar levels) Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units call md if above 400 subcutaneously three times a day for diabetes and Basaglar solution (a long-acting insulin) inject 24units subcutaneously at bedtime. On 06/05/25 at 10:04 AM, during an interview with Surveyor #1, Resident #77 said that he/she had concerns with receiving medications late. A review of Resident #77's Medication Administration Audit Report for May 2025 and June 2025 revealed the Insulin Regular Human Injection Solution for diabetes was administered past the required time frame as follows: 05/02/2025 at 12:00 PM administered at 02:55 PM 05/03/2026 at 04:30 PM administered at 07:52 PM 05/04/2025 at 08:00 AM administered at 09:43 AM 05/04/2025 at 12:00 PM administered at 01:22 PM 05/06/2025 at 08:00 AM administered at 10:01 AM 05/08/2025 at 04:30 PM administered at 05:39 PM 05/11/2025 at 12:00 PM administered at 01:21 PM. 05/11/2025 at 04:30 PM administered at 06:54 PM 05/12/2025 at 08:00 AM administered at 01:15 PM 05/12/2025 at 12:00 PM administered at 01:09 PM 05/12/2025 at 04:30 PM administered at 08:48 PM 05/14/2025 at 12:00 PM administered at 01:28 PM 05/15/2025 at 12:00 PM administered at 01:15 PM 05/16/2025 at 12:00 PM administered at 01:20 PM 05/17/2025 at 12:00 PM administered at 01:45 PM 05/18/2025 at 08:00 AM administered at 10:37 AM 05/19/2025 at 12:00 PM administered at 02:37 PM 05/19/2025 at 04:30 PM administered at 06:13 PM 05/22/2025 at 08:00 AM administered at 01:04 PM 05/22/2025 at 12:00 PM administered at 01:05 PM 05/23/2025 at 08:00 AM administered at 11:24 AM 05/23/2025 at 12:00 PM administered at 02:45 PM 05/24/2025 at 04:30 PM administered at 11:55 PM 05/25/2025 at 08:00 AM administered at 11:12 AM 05/25/2025 at 04:30 PM administered at 05:57 PM 05/26/2025 at 08:00 AM administered at 09:09 AM 05/26/2025 at 12:00 PM administered at 01:22 PM 05/28/2025 at 04:30 PM administered at 05:46 PM 06/03/2025 at 08:00 AM administered at 09:56 AM 06/04/2025 at 04:30 PM administered at 05:36 PM 06/05/2025 at 04:30 PM administered at 05:41 PM A review of Resident #77's Medication Administration Audit Report for May 2025 and June 2025 revealed the Basaglar solution (a long-acting insulin) was administered past the required time frame as follows: 05/04/2025 at 09:00 PM administered at 10:52 PM 05/05/2025 at 09:00 PM administered on 10:16 PM 05/08/2025 at 09:00 PM administered at 10:11 PM 05/09/2025 at 09:00 PM administered at 10:18 PM 05/16/2025 at 09:00 PM administered on 05/17/2025 at 12:38 AM 05/17/2025 at 09:00 PM administered at 10:34 PM. 05/21/2025 at 09:00 PM administered at 10:12 PM 05/24/2025 at 09:00 PM administered at 11:56 PM 05/28/2025 at 09:00 PM administered at 10:51 PM 06/01/2025 at 09:00 PM administered at 10:36 PM 06/03/2025 at 09:00 PM administered at 11:29 PM 06/06/2025 at 09:00 PM administered at 10:46 PM 06/07/2025 at 09:00 PM administered at 11:05 PM During an interview with Surveyor #1 on 06/06/2025 at 10:55 AM, the Licensed Practical Nurse (LPN) #1 said that medication should be administered an hour before or an hour after the scheduled administration time. She further said that the nurse should document that a medication is administered right after the medication is given. During an interview with Surveyor #1 on 06/1020/25 at 10:02 AM, the Unit Manager of Unit 2 said that insulin should be administered according to the order. She further said that insulin should not be given late. During an interview with Surveyor #1 on 06/12/2025 at 10:14 AM, the Director of Nursing said she reviewed Resident #77's medication audit and acknowledged that this resident's insulin was administered late. A review the facility policy titled, Timely Administration of Insulin dated 9/1/2024 revealed that, It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident to prevent adverse effects on a resident's condition. The policy further revealed, 1. All insulin will be administered in accordance with physician's orders. and lastly, 4. Insulin administration will be coordinated with meal times and bedtime snacks unless otherwise specified in the physician order. A review Resident # 110's diagnoses located in the Electronic Medical Record (EMR) include but are not limited to Type 2 Diabetes Mellitus (the body's inability to use insulin properly, leading to high blood sugar levels) and End Stage Renal Disease (a condition where the kidneys no longer function properly and cannot effectively filter waste and excess fluid from the blood). A review of Resident # 110's physician's orders located in the EMR revealed orders for Insulin Lispro Injection Solution to inject as per sliding scale: if 180 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 999 = 12 units And call MD [Medical Doctor] for insulin dose subcutaneously before meals for DM [Diabetes Mellitus]. A review of the facility meal times that were provided during the Entrance Conference reflect the following times: Breakfast - 7:30 AM - 8:30 AM Lunch - 12:00 PM - 1:00 PM Dinner - 4:00 PM - 5:00 PM A review of the Medication Audit Report located in the EMR revealed the scheduled time of administration for the insulin and the actual administration times: Scheduled Date 5/1/2025 at 4:30 PM; Administration Time 8:52 PM Scheduled Date 5/2/2025 at 8:00 AM; Administration Time 9:22 AM Scheduled Date 5/2/2025 at 11:30 AM; Administration Time 2:02 PM Scheduled Date 5/6/2025 at 4:30 PM; Administration Time 5:48 PM Scheduled Date 5/10/2025 at 4:30 PM; Administration Time 6:17 AM on 5/11/2025 Scheduled Date 5/11/2025 at 8:00 AM; Administration Time 11:09 AM Scheduled Date 5/11/2025 at 11:30 AM; Administration Time 4:03 PM Scheduled Date 5/11/2025 at 4:30 PM; Administration Time 5:58 PM Scheduled Date 5/13/2025 at 4:30 PM; Administration Time 6:07 PM Scheduled Date 5/14/2025 at 8:00 AM; Administration Time 10:04 AM Scheduled Date 5/14/2025 at 11:30 AM; Administration Time 1:29 PM Scheduled Date 5/17/2025 at 4:30 PM; Administration Time 6:18 PM Scheduled Date 5/18/2025 at 4:30 PM; Administration Time 5:34 PM Scheduled Date 5/20/2025 at 4:30 PM; Administration Time 6:25 PM Scheduled Date 5/20/2025 at 9:00 PM; Administration Time 11:05 PM Scheduled Date 5/23/2025 at 8:00 AM; Administration Time 11:39 AM Scheduled Date 5/23/2025 at 11:30 AM; Administration Time 3:37 PM Scheduled Date 5/23/2025 at 4:30 PM; Administration Time 8:53 PM Scheduled Date 5/24/2025 at 6:00 PM; Administration Time 7:30 PM Scheduled Date 5/24/2025 at 9:00 PM; Administration Time 10:15 PM Scheduled Date 5/26/2025 at 11:30 AM; Administration Time 12:43 PM Scheduled Date 5/27/2025 at 9:00 PM; Administration Time 10:55 PM Scheduled Date 5/28/2025 at 4:30 PM; Administration Time 10:08 PM Scheduled Date 5/30/2025 at 11:30 AM; Administration Time 1:06 PM Scheduled Date 6/03/2025 at 11:30 AM; Administration Time 1:39 PM During an interview with the surveyor, the Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed that Resident # 110 does receive insulin. She denied that Resident # 110 had a history of refusing medications. The UM/LPN denied Resident # 110 had any hypoglycemic episodes. She said that it is important that he/she get insulin at the prescribed time to accommodate his/her meal times to prevent hypoglycemic episodes. A review the facility policy titled, Timely Administration of Insulin dated 9/1/2024 revealed that, It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident to prevent adverse effects on a resident's condition. The policy further revealed, 1. All insulin will be administered in accordance with physician's orders. and lastly, 4. Insulin administration will be coordinated with meal times and bedtime snacks unless otherwise specified in the physician order. 3. On approximately 6/10/2025 at 11:30 AM, the surveyor reviewed the medical record for Resident #28. A review of the [admission Record], an admission summary, revealed the resident had diagnoses which included, but were not limited to: Fracture of the right radial styloid process (fracture at the base of the thumb which is significant because of the its impact of the wrist function). A review of the medication audit report from 4/01/2025 -6/10/25 which reflected that order for Insulin Glargine Subcutaneous Solution 100u/mL (units/mililiter] to inject 15 unit subcutaneous in the morning (7:30 AM), with an order date of 4/24/2025 and discontinue date of 5/29/2025, was administered late on the following dates and times: 5/2/25 ordered for 7:30 AM and administered at 8:42 AM 5/6/25 ordered for 7:30 AM and administered at 9:30 AM 5/9/25 ordered for 7:30 AM and administered at 9:09 AM 5/10/25 ordered for 7:30 AM and administered at 9:13 AM 5/11/25 ordered for 7:30 AM and administered at 9:43 AM 5/12/25 ordered for 7:30 AM and administered at 8:59 AM 5/13/25 ordered for 7:30 AM and administered at 8:58 AM 5/14/25 ordered for 7:30 AM and administered at 9:19 AM 5/15/25 ordered for 7:30 AM and administered at 12:04 PM 5/18/25 ordered for 7:30 AM and administered at 8:44 AM 5/20/25 ordered for 7:30 AM and administered at 8:54 AM 5/22/25 ordered for 7:30 AM and administered at 8:32 AM 5/24/25 ordered for 7:30 AM and administered at 9:10 AM 5/25/25 ordered for 7:30 AM and administered at 9:50 AM 5/31/25 ordered for 7:30 AM and administered at 8:37 AM 6/2/25 ordered for 7:30 AM and administered at 8:40 AM 6/3/25 ordered for 7:30 AM and administered at 8:36 AM 6/8/25 ordered for 7:30 AM and administered at 8:50 AM A review of the medication audit report from 4/01/2025 -6/10/25 which reflected that order for Insulin Lispro Solution 100u/mL- Inject 15 unit subcutaneously before meals (7:30 AM; 11:30 AM; 4:30 PM), with an order date of 4/24/2025 and discontinue date of 5/29/2025, was administered late on the following dates and times: 5/2/25 ordered for 7:30 AM and administered at 8:42 AM 5/6/25 ordered for 7:30 AM and administered at 9:30 AM 5/9/25 ordered for 7:30 AM and administered at 9:09 AM 5/10/25 ordered for 7:30 AM and administered at 9:13 AM 5/10/25 ordered for 11:30 AM and administered at 12:37 PM 5/11/25 ordered for 7:30 AM and administered at 9:43 AM 5/11/25 ordered for 11:30 AM and administered at 3:33 PM 5/12/25 ordered for 7:30 AM and administered at 8:59 AM 5/13/25 ordered for 7:30 AM and administered at 8:58 AM 5/13/25 ordered for 11:30 AM and administered at 1:04 PM 5/13/25 ordered for 4:30 PM and administered at 5:56 PM 5/14/25 ordered for 7:30 AM and administered at 9:19 AM 5/14/25 ordered for 11:30 AM and administered at 1:18 PM 5/15/25 ordered for 7:30 AM and administered at 12:04 PM 5/16/25 ordered for 11:30 AM and administered at 2:22 PM 5/16/25 ordered for 4:30 PM and administered at 5:57 PM 5/18/25 ordered for 7:30 AM and administered at 8:44 AM 5/20/25 ordered for 11:30 AM and administered at 12:33 AM 5/20/25 ordered for 4:30 PM and administered at 8:39 PM 5/22/25 ordered for 7:30 AM and administered at 8:32 AM 5/22/25 ordered for 11:30 AM and administered at 1:01 PM 5/22/25 ordered for 4:30 PM and administered at 5:54 PM 5/23/25 ordered for 11:30 AM and administered at 1:37 PM 5/23/25 ordered for 4:30 PM and administered at 5:44 PM 5/24/25 ordered for 7:30 AM and administered at 9:10 AM 5/24/25 ordered for 11:30 AM and administered at 1:09 PM 5/25/25 ordered for 7:30 AM and administered at 9:50 AM 5/25/25 ordered for 11:30 AM and administered at 12:58 PM 5/28/25 ordered for 4:30 PM and administered at 5:49 PM 5/29/25 ordered for 11:30 AM and administered at 12:31 PM 5/29/25 ordered for 4:30 PM and administered at 5:54 PM 5/30/25 ordered for 4:30 PM and administered at 5:50 PM 5/31/25 ordered for 7:30 AM and administered at 8:37 AM 6/1/25 ordered for 11:30 AM and administered at 12:32 PM 6/1/25 ordered for 4:30 PM and administered at 5:48 PM 6/3/25 ordered for 7:30 AM and administered at 8:36 AM 6/4/25 ordered for 4:30 PM and administered at 5:46 PM 6/8/25 ordered for 7:30 AM and administered at 8:50 AM 6/8/25 ordered for 4:30 PM and administered at 5:47 PM A review of the medication audit report from 4/01/2025 -6/10/25 which reflected that order for Insulin Lispro Solution 100u/mL- Inject 30 unit subcutaneously at bedtime (9:00 PM), with an order date of 4/24/2025 and discontinue date of 5/29/2025, was administered late on the following dates and times: 5/6/25 ordered for 9:00 PM and administered at 10:17 PM 5/20/25 ordered for 9:00 PM and administered at 10:49 PM 5/22/25 ordered for 9:00 PM and administered at 11:04 PM 5/29/25 ordered for 9:00 PM and administered at 10:13 PM 5/30/25 ordered for 9:00 PM and administered at 12:46 PM 6/8/25 ordered for 9:00 PM and administered at 10:13 PM N.J.A.C. 8.39-29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to consistently document enteral tube feeding flush administration to assure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 1 of 1 residents (Residents #5), reviewed for enteral tube feeding and was evidenced by the following: Review of the admission Record (admission summary) reflected that Resident #5 was admitted to the facility with the diagnoses that included but was not limited to; acute respiratory failure, aphasia (difficulty expressing self or difficulty in processing language), dysphasia (swallowing problems) and epilepsy (seizures). Review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 5/23/25, indicated that Resident #5 had short and long-term memory deficits. The resident was severely impaired for decision making and required maximum assistance with activities of daily living (ADLs). The MDS also indicated that the resident received nutritional, and hydration needs through the peg tube (Percutaneous endoscopic gastrostomy (PEG) is a feeding tube inserted through the abdominal wall into the stomach). On 6/5/25 at 11:27 AM, the surveyor observed Resident #5 dressed and up in a reclining chair out by the nurse's station. The surveyor attempted to interview the resident however the resident could not verbalize. The surveyor was unable to interview the resident due to intellectual developmental disabilities. The surveyor reviewed the resident electronic medical records (EMR) which revealed the following information: A review of the Medication Review Report (MRR) contained a physician order (PO) dated 4/4/25, to flush the peg tube with 185cc (cubic centimeters) of tap water prior to and after feeding. This would equal 370 cc of water that should have been administered four times a day with each feeding. This would equal to 1480 ml (mililiters) of free water flushes a day. A review of the Registered Dietician note dated 5/21/2025 at 12:01PM, indicated that Resident #5 was to have free water flushes four times a day with tap water, 185 ml before and after each bolus feed to equal 1480 ml. A review of the Medication Administration Record (MAR) dated 4/4/25 at 8:00 PM to 4/30/25, reflected a physician's order to flush the peg tube with 185 cc of tap water prior to and after tube feeding. The nursing documentation on the MAR revealed that the facility had 105 opportunities to administer the correct peg tube water flushes, however the nurses documented the wrong amount of physician ordered water flushes 76 out of 105 opportunities. A review of the MAR dated 5/1/25 to 5/31/25, reflected a physician's to flush the peg tube with 185cc of tap water prior to and after tube feeding. The nursing documentation on the MAR revealed that the facility had 124 opportunities to administer the correct peg tube water flushes, however the nurses documented the wrong amount of water flushes 121 out of 124 opportunities. A review of the MAR dated 6/1/25 to 6/9/25 at 6:00 am, reflected a physician's order to flush the peg tube with 185cc of tap water prior to and after tube feeding. The nursing documentation on the MAR reflected that the facility had 33 opportunities to administer the correct peg tube water flushes, however the nurses documented the wrong amount of flushes 25 out of 33 opportunities. On 6/5/25 at 12:50, the surveyor observed the Licensed Practical Nurse (LPN) administer the peg tube feeding. The LPN applied a gown, gloves and mask and proceeded to bring an irrigation set filled to 200cc of water into the resident's room. The LPN attached the piston syringe to the residents peg tube. Prior to administration of the water flush, the surveyor asked the LPN what the calibration was on the piston syringe. The LPN stated that the piston syringe held 60 cc of fluid. The LPN then proceeded to fill the piston syringe with water two times to equal 120cc. She then flushed the peg tube prior to the administration of the formula. After the administration of the formula, the LPN then proceeded to flush the peg tube using the piston syringe. She filled the piston syringe with water two times to equal 120cc. The LPN was interviewed at this time and stated that she flushed the peg with a total of 185 cc of water prior to and after the feeding. The surveyor asked the LPN why she only filled the piston syringe with water two times that equaled 120cc and she admitted that she did not give 185cc of water prior to and after the residents feeding. The LPN reviewed the physician's order with the surveyor and confirmed that the order was to flush the peg tube with 185cc of water prior to and after the feeding. The LPN agreed and stated that she would have to clarify the order with the physician. On 6/06/25 at 9:57 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who reviewed Resident #5's physician's orders in the presence of the surveyor and stated that Resident #5 was to be administered 185ml of water before and after each feeding. The ADON agreed that according to the documentation on the MAR from April 2025 until surveyor inquiry in June 2025, the nurses were not consistently administering the correct peg tube flushes prior to and after the residents feeding. She stated that the nurses should be documenting that they administered 370 cc of water total flushes four times a day on the MAR, but instead were documenting 185 cc as well as different amounts as the total flush four times a day. She said that the nurses did not correctly document the total amount correctly on the MAR and stated they should have documented that they flushed the peg tube with 185cc prior to and after the feeding to equal 370 cc. She stated that when the surveyor observed the LPN perform the peg tube flushes the LPN should not have used the piston syringe to measure how much water flushes the resident was to receive and should have used a medication cup that had increment measurements of 5 cc. She stated that the LPN should have administered 185 cc of water prior to and after the resident's feeding as ordered by the physician. On 6/6/25 at 10:12 AM, the surveyor interviewed the Registered Dietician who stated that it was important to follow the physician's orders to assure proper fluid and hydration status for every resident, especially residents fed by a tube feed. She stated that tube fed residents were usually NPO and this is the only way they could obtain adequate amounts of fluid. The RD reviewed Resident #5's MAR in the presence of the surveyor and verified that when the nurses documented 185 cc on the MAR, that would indicate that the nurses only gave 185cc total flush at that time. She stated that since the physician's order indicated that 185cc was to be administered prior to and after the resident's feeding, the nurses should have documented a total of 370 cc of water each time the resident received a tube feeding. She stated that 370 cc of water four times a day would equal to 1,480cc a day of free fluid a day and that the dietician had documented this in the nutritional notes. She stated that by not administering the correct amount of water flushes, the resident could become dehydrated, but according to the resident's labs the resident had no indication that they were having issues pertaining to dehydration. Review of the Physician/Nurse Practitioner (NP) notes dated 6/10/2025 indicated that the resident's labs were reviewed, and that the resident was stable and in no acute distress. 06/10/25 09:37 AM, the surveyor interviewed the Regional Clinical Coordinator Registered Nurse (RCC/RN) and Director of Nursing (DON) who both verified that the nurses documented the wrong total amount of flushes that were provided to the resident prior to and after the feeding. She stated that the resident should have received 185 cc of tap water prior to and after feeding to equal 370cc of water with each feeding. A review of the facility policy dated 9/1/24 and titled, Appropriate Use of Feeding Tubes indicated that the facility would ensure that a resident maintains acceptable parameters of nutritional and hydration status. A review of the facility policy dated 9/1/24 and titled Medication Orders indicated that medications should be administered only upon the signed order of a person lawfully authorized to prescribe. Each medication order should be documented, and the order should be recorded in the physician's order and MAR. A review of the facility policy dated 10/1/2024 and titled, Documentation in the Medical Record indicated that each residents medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a pciture of the resident's progress through complete, accurate, and timely documentation. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for 1 of 34 residents reviewed, Resident #18 as evidenced by the following: Upon initial tour of the Unit 2 on 06/04/2025 at 9:52 AM, the surveyor observed an individual outside room [ROOM NUMBER] putting on personal protective equipment. The surveyor observed the individual's uniform displaying a hospice name and she identified herself as a hospice aide caring for Resident #18. On 06/06/2025 at 10:23 AM, the surveyor observed Resident #18 in resting in bed with family in room holding their hand. Resident #18 was admitted to the facility on [DATE] with diagnosis that included Multiple Sclerosis. A review of the Physician's Orders identified an order for Hospice Evaluation and Treatment on 2/3/2025. The surveyor reviewed the MDS assessments for Resident #18. A SCSA MDS was not completed for the change in status for Resident #18. SCSA MDS is a federally mandated process comprehensive assessment that is required when a resident enrolls in a hospice program and must be completed within 14 days after the determination date to ensure that the resident will be assessed. The comprehensive assessment must include a care plan meeting with the Interdisciplinary Team to provide the resident the best quality of care. During an interview with the surveyor on 06/06/2025 at 11:24 AM, the MDS Coordinator (MDSC) stated that a SCSA MDS was required with a resident change in status like hospice and should be completed in 14 days. When asked if a SCSA could be included in a quarterly assessment, the MDSC denied. The surveyor requested that the MDSC review the submitted MDS assessments for Resident #18. The MDSC responded that the hospice was captured in the Quarterly Assessment on 3/24/2025. The surveyor inquired if a significant change should have been completed for Resident #18 and the MDSC agreed. On 06/12/2025 at 10:09 AM, during an interview with the Director of Nursing (DON) , in the presence of the Licensed Nursing Home Administrator (LNHA) Regional Clinical Director of Nursing (RCDON), Regional Administrator (RD), acknowledged that SCSA MDS should have been submitted. A review of the facility's Conducting an Accurate Resident Assessment Policy, Reviewed/Revised on 3/1/2025, identified under the Policy: The purpose of this policy is to assure that all residents receive and accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. NJAC 8:39- 11.2(i)

Based on observation, interview and record review it was determined that the facility failed to maintain the necessary respiratory care and services for 1 of 2 residents (Resident #74) reviewed. This deficient practice was evidenced by: A review of the admission Record (admission summary) indicated that Resident #74 was admitted to the facility with the diagnoses which included but was not limited to respiratory conditions due to other external agents, chronic respiratory failure with hypoxia (a condition that occurs when the body tissues do not get sufficient oxygen supply) and chronic obstructive pulmonary disease (COPD) (an ongoing lung condition caused by damage to the lungs). A review of the quarterly Minimum Data Set (MDS) an assessment that facilitates a resident's care dated 4/11/25, indicated that Resident #74 scored a 14 on the basic interview for mental status (BIMS) which indicated that the resident was cognitively intact. The MDS also indicated that the resident required supervision with activities of daily living (ADL's) and was on oxygen (O2). On 6/5/25 at 10:39 AM, the surveyor observed Resident #74 lying in bed, fully dressed and watching TV. The resident was observed utilizing oxygen by way of [via] nasal cannula (a tube that delivers oxygen into the nostrils). The resident was not in respiratory distress. The resident stated they had the diagnoses of chronic obstructive pulmonary disease (COPD). The surveyor did not observe that the resident was on humidification with the oxygen and there was no humidification on the oxygen concentrator (device that concentrates the oxygen from a gas supply). On 6/6/25 at 09:50 AM, the surveyor observed that the resident continued on oxygen and there was no humidification hooked to the concentrator. The surveyor reviewed the resident's electronic medical records (EMR) which revealed the following information: A review of the Order Summary Report (OSR) dated 12/13/24, contained an order to administer oxygen at 4 liters per minute continuously with humidification every shift for diagnoses of COPD. The Interdisciplinary Care Plan (ICP) dated 4/4/2024, reflected a focus that indicated Resident #74 was at risk for alteration in respiratory status and difficulty breathing related to a history of acute and chronic COPD. The ICP specified that Resident #74 was utilizing O2 via nasal cannula at 4 L/min continuous with humidification. On 6/6/25 at 10:35 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that Resident #74 was alert oriented and able to make needs known. The CNA stated that the resident was incontinent at times but only when having difficulty with breathing. She stated that the resident had COPD and was on O2 continuously. She stated that the O2 tubing was hooked straight into concentrator and that the resident's oxygen was not humidified. On 6/6/25 at 10:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she worked for the agency. She stated that Resident #74 requires one person to assist with care and ADLs. She stated that the resident was on O2 at 4 liters/min however humidification was not required. The LPN reviewed the physician orders in the presence of the surveyor and admitted that the physician ordered the O2 to be administered with humidification and that she would obtain it immediately. On 6/6/25 11:12 AM, the Assistant Director of Nursing (ADON) stated that if the resident's physician ordered the resident to receive humification with O2 administration, then the nurses were responsible to assure that humidification bottle was present on the O2 concentrator. On 6/6/25 at 12:06 PM, the surveyor observed the resident lying in bed with humidified O2 on at 4 liters per minute. The resident stated that the humidification bottle was just applied after surveyor inquiry. The resident added that they had not had the humidification for a while and that their nose would get dry at times and bleed. A review of the facility policy dated 9/1/24 and titled, Oxygen Administration indicated that oxygen therapy was administered under the orders of a physician and that the resident's care plan shall identify the interventions for oxygen therapy based on the resident's assessment and orders. The policy also indicated that the equipment needed for oxygen administration will depend on the type of delivery system ordered to include humidity bottle and tubing. NJAC 8:39-27.1(a)

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 1 of 3 nursing units observed for environment and evidenced by the following: Upon initial tour of Unit 2 on 06/04/2025 at 10:24 AM, the surveyor observed a nurse's call bell wall unit depressed through the drywall with medical tape securing it to the wall. On 06/06/2025 at 11:11 AM, the surveyor observed the same nurse's call bell unit depressed through the drywall with medical tape securing it to the wall. During an interview with the surveyor on 06/06/2025 at 11:17 AM Certified Nursing Assistant (CNA#1) indicated that their responsibilities included daily check of the resident's room to make sure everything was in a safe working order. On 06/11/2025 at 10:32 AM, the surveyor requested that Licensed Practical Nurse Unit Manager (LPN/UM#1) to accompany them in room [ROOM NUMBER]. Both LPN/UM#1 and the surveyor received permission from the resident to enter their room. The surveyor pointed out the nurse's call bell wall unit. LPN/UM#1 acknowleged that she would think that it should not be that way. When asked if it's condition should have been reported, the LPN/UM#1 responded that the nurses and CNA's may not have noticed it. The surveyor requested that LPN/UM#1 activate the call bell system and then clear it. The surveyor observed as LPN/UM#1 approached the wall unit and place her finger inside the depressed area of the drywall in order to clear the call alarm. At this time, LPN/UM#1 stated that she would have expected that the wall unit would have been reported. On 06/11/2025 at 12:59 PM, during an interview with the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Regional Clinical Director of Nursing (RCDON), and Regional Administrator (RD), confirmed that there should not be broken items or items taped to resident walls. A review of the facility's Safe and Homelike Environment Policy, Implemented on 9/1/2024, identified under the Policy Explanation and Compliance Guidelines: [ .]Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. NJAC 8:39-4.1(a)11; 31.1(b)

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure that a resident's Interdisciplinary Care Plan (ICP) was resident specific and reflected accurate resident care. The deficient practice was identified for 1 of 23 residents (Resident #5) reviewed and was evidenced by the following: A review of the admission Record (admission summary) reflected that Resident #5 was admitted to the facility with the diagnoses that included but was not limited to; acute respiratory failure, aphasia (difficulty expressing self or difficulty in processing language), dysphasia (swallowing problems) and epilepsy (seizures). A review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 5/23/25, indicated that Resident #5 had short and long-term memory deficits. The resident was severely impaired for decision making and required maximum assistance with activities of daily living (ADLs). The MDS also indicated that the resident received nutritional, and hydration needs through the PEG tube (a feeding tube inserted through the abdominal wall into the stomach). A review of the resident's Order Summary Report (OSR), dated 4/4/2025, included the following physician's orders (PO) for the resident to have NPO (Nothing by mouth) diet, NPO texture, NPO consistency and enteral feed. A PO dated 4/4/25, reflected an order to flush the PEG tube with 185 ml (mililiters) before and after each bolus feed, four times a day with tap water. A review of the resident's Interdisciplinary Care Plan (ICP) indicated the following: A focus area dated 2/1/25, indicated an alteration in gastro-intestinal status (NPO), related to dysphagia (difficulty or inability to swallow). Interventions included: encourage the resident to avoid alcohol, smoking, coffee (even decaffeinated), fatty foods, chocolate, citrus juices, [NAME], tomato products, garlic, onions, and encourage a bland diet, however the resident was to have nothing by mouth. A focus area dated 2/3/25, indicated a swallowing problem related to a swallowing assessment result and that the resident was unable to elicit mouth opening for trials of food or liquid. The intervention included that all staff were to be informed of the resident's special dietary and safety needs, however the resident was to have nothing by mouth. A focus area dated 3/7/25, indicated Resident #5 had a potential for fluid deficit related to the feeding tube. The interventions included: educate the resident/family/caregivers on importance of fluid intake, encourage the resident to drink fluids of choice, and monitor and document intake and output as per facility policy, however the resident was to have nothing by mouth. A focus area dated 3/7/25 indicated that Resident #5 had a feeding tube to help meets needs due to the resident not being able to safely eat. The intervention reflected that Resident #5 was to receive 250 ml of free water fluid (FWF) every four hours. The ICP was not updated to reflect the physician's order that the resident was to receive 185cc of tap water prior to and after feeding. On 6/6/25 at 09:57 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who explained that the ICP was resident specific and should provide an accurate description of the resident's needs. The ADON stated that Resident #5 ICP had multiple inaccuracies. The ADON stated that the ICP should not indicate that the resident should be encouraged to drink fluids or eat a bland diet as the physician ordered that the resident maintain an NPO status. The surveyor asked the ADON if the resident was able to use the call bell to ask for assistance as written on the ICP. The ADON stated that she did not think that the resident could use a call bell, and it should not have been on the ICP. On 6/6/25 at 10:12 AM, the surveyor interviewed the Registered Dietician (RD), who reviewed Resident #5's ICP that indicated that the resident had a fluid volume deficit and should be encouraged to drink fluids. The RD stated that this would not be an appropriate care plan because the resident was NPO and was to not to receive anything by mouth. On 6/6/25 at 11:54 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1), who explained that Resident #5 required total care with all aspects of activities of daily living (ADL's). The CNA stated that that she was unsure if the resident could use the call bell and that she did not think that the resident could. The CNA could not immediately recall the resident's feeding status or that the resident was NPO. Another CNA (CNA #2), who was at the nurses' station during the interview, stated that Resident #5 could not use the call bell and received nothing by mouth. On 6/9/25 at 08:39 AM, the surveyor interviewed DOR, who stated that the Resident #5 did not have a specific evaluation for call bell usage and the Resident was not cognitively intact to use any type of call bell system. The DOR explained that staff anticipated the resident's needs and were required to check on the resident every couple of hours. The DOR verified that the resident could not use the call bell and that it should not be part of the resident's care plan. On 6/9/25 at 12:26 PM, the surveyor interviewed the MDS Coordinator (MDSC) who had been the MDSC since November and only had the responsibility to ensure that the ICP matched the resident's diagnoses. The MDSC explained that the unit manager, dietician, social worker, and activities director were responsible for updating, revising, and ensuring the accuracy of the ICP. On 6/10/25 at 10:54 AM, the surveyor interviewed the Regional Clinical Director (RCD) and Director of Nursing (DON) who stated that the purpose of a ICP was to outline a residents' healthcare needs and should be resident specific and person centered. The RCD and DON in the presence of the surveyor, reviewed the resident's ICP. Both verified the discrepancies stated above did not reflect the resident's current healthcare needs and were not appropriate for the resident's care. The facility policy Comprehensive Care Plans dated 9/1/2024, indicated that it was 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 psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The facility policy Documentation in Medical Record dated 10/1/2024, indicated that each resident's medical record shall contain an accurate representation of the actual experiences of the rident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. NJAC 8:39-11.2 (1), (2), 12.1, 27.1 (a)

Complaint #: NJ183557 Based on interview and review of facility documents on 5/22/25, it was determined that the facility failed to ensure a Registered Nurse (RN) worked for at least eight consecutive hours a day for 1 of 21 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Reports completed by the facility for the weeks of 02/09/25 through 02/15/25, 04/06/2025 through 04/12/2025, and 04/13/2025 through 04/119/25, revealed that the facility had no RN coverage for all shifts on 02/09/25 The surveyor reviewed the facility's policy titled Nursing Services and Sufficient Staff updated 03/05/25 which indicated, It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. NJAC 8:39-25.2(h)

Complaint #: NJ183557 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 04/24/2025 and 04/29/2025, it was determined that the facility failed to follow standards of clinical practice for Physician Orders (POs) for medication administration and follow the Care Plan (CP) interventions for a resident (Resident #5). The facility also failed to follow its policy titled Medication Administration. This deficient practice was identified for 1of 6 residents reviewed for medication administration and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey 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. According to Resident #5's admission Record (AR), the resident was admitted with diagnoses that included but were not limited to: Acute and Chronic Respiratory Failure with Hypercapnia (an impairment of gas exchange, resulting in dangerously high CO2 levels in the blood), Chronic Obstructive Pulmonary Disease (COPD) (a lung condition that causes airflow obstruction), and Hypertension (high blood pressure). According to the Minimum Data Set (MDS), an assessment tool dated 02/20/2025, Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. According to Resident #5's CP with a date of 03/07/2025, under Focus revealed: Resident #5 requires oxygen therapy r/t (related to) end stage COPD, under Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. According to Resident #2's Order Summary Report (OSR) Active Orders as of 02/01/2025, the OSR revealed a physician order for the following medication: Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml (milligram/milliliter). Give 0.25 ml by mouth four times a day for air hunger. 0.25 ml=5mg at 04:00 A.M., 09:00 A.M, 01:00 P.M, 05:00 P.M with a start date of 8/10/23. Review of Resident #5's Electronic Medication Administration Record (eMAR) showed medication was not administered on the following date and time. Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml (milligram/milliliter). Give 0.25 ml by mouth four times a day for air hunger. 0.25 ml=5mg at 04:00 A.M. Review of Resident #5's Individual Patient Controlled Substance Administration Record (declining inventory used for narcotics) for Morphine, there was no evidence of administration on the date above. The Licensed Practical Nurse (LPN) who did not administer Resident #5's Morphine was unable to be reached for an interview during the survey. On 04/24/2025, at 01:53 P.M., during an interview with the surveyor, the Licensed Practical Nurse (LPN), stated medication should be administered within the ordered time frame and the order is verified. She further stated, if a resident refuses medications staff should document the refusal via eMAR and progress notes. She stated blank eMAR would indicate someone didn't sign and that means the medication was not given. On 04/274/2025, at 2:49 P.M., during an interview with the surveyor, the Director of Nursing (DON), We don't expect blanks on a MAR. Expectation is that my staff should do the five rights of med (medication) administration.The DON said if a medication is administered, it should be immediately documented by the administering nurse in the resident's eMAR. She further stated facility policy is to document all medications and there should be no blank spaces. When presented with Resident #5's eMAR for 02/2025, the DON confirmed the blank space for Morphine and that the medication was not given as ordered. Review of the facility policy titled Medication Administration with an implemented date of 09/01/2024 under Policy reveals: medications are administered by licensed nurses, or staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under Policy Explanation and Compliance Guidelines: #21. Sign MAR after administered. For those medications requiring vital signs, record vitals onto the MAR. NJAC 8:39- 11.2 (b)

Complaint # NJ00181615, NJ00177959 Based on observations, interviews, and record review, as well as a review of pertinent facility documents on 12/23/24, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice by not ensuring that a medication [Sucralfate], an anti-ulcer medication, was administered to a resident (Resident #1) in a timely manner as ordered by a physician. Sucralfate was a medication to be administered before meals. This deficient practice was observed in 1 of 4 residents reviewed for medication administration and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the Admission Record (AR), Resident #1 was admitted to the facility with diagnoses including but not limited to: Urinary Tract Infection, Hypertension, Paraplegia, Autonomic Dysreflexia, Neuromuscular Dysfunction of Bladder, Personality Disorder, Colostomy Status, Gastro-Esophageal Reflux Disease without Esophagitis, and Mood Disorder. A review of Resident #1's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 10/15/2024, indicated Resident #1's Brief Interview for Mental Status (BIMS) Score was 15 revealing the Resident's cognition was intact. The MDS further revealed in Section GG-Functional Abilities and Goals that Resident #1 required assistance in his/her completion of Activities of Daily Living (ADLs). A review of Resident #1's Order Summary Report (OSR) with Active Orders As of: 12/20/2024 revealed an order for the following: Sucralfate Oral Tablet 1 GM [gram] (Sucralfate) Give 1 tablet by mouth before meals and at bedtime for GERD [Gastro-esophageal reflux disease, a chronic disease that occurs when stomach acid flows back into the food pipe and irritates the lining] with an Order and Start Date of 09/15/2024. A review of Resident #1's electronic Medication Administration Record (eMAR) dated 11/1/2024-11/30/2024 indicated the abovementioned medication was scheduled and to be administered as follows: Sucralfate Oral Tablet 1 GM [gram] (Sucralfate) Give 1 tablet by mouth before meals and at bedtime for GERD at 0730 [7:30 in the morning], 1130 [11:30 in the morning], 1630 [4:30 in the afternoon], and at bedtime 2100 [9:00 in the evening]. A review of Resident #1's eMAR Resident Details (RD), under the Administration Details revealed that the above-mentioned medication was administered as follows: Sucralfate Oral Tablet 1 GM (Sucralfate) was scheduled to be administered at 0730 [morning], 1130 [morning], 1630 [4:40 afternoon], and at 2100 [9:00 evening], however, on the following days the medication was given late as follows: 11/5/2024 0730 - medication was administered at 08:45 [morning] 11/5/2024 1130 - medication was administered at 13:52 [1:52 in the afternoon] 11/5/2024 1630 - medication was administered at 17:26 [5:26 in the afternoon] 11/6/2024 0730 - medication was administered at 8:56 [morning] 11/6/2024 1130 - medication was administered at 12:50 [afternoon] 11/7/2024 0730 - medication was administered at 10:52 [morning] 11/8/2024 1630 - medication was administered at 19:46 [7:46 in the evening] 11/9/2024 0730 - medication was administered at 10:02 [morning] 11/9/2024 1630 - medication was administered at 17:47 [5:47 in the afternoon] 11/10/2024 0730 - medication was administered at 09:14 [morning] 11/11/2024 0730 - medication was administered at 10:18 [morning] 11/11/2024 1130 - medication was administered at 13:17 [1:17 in the afternoon] 11/12/2024 0730 - medication was administered at 08:58 [morning] 11/12/2024 1130 - medication was administered at 13:52 [1:52 in the afternoon] 11/12/2024 1630 - medication was administered at 17:43 [5:43 in the afternoon] 11/13/2024 0730 - medication was administered at 09:37 [morning] 11/13/2024 1130 - medication was administered at 14:00 [2:00 in the afternoon] 11/14/2024 0730 - medication was administered at 09:34 [morning] 11/14/2024 1630 - medication was administered at 18:57 [6:57 in the evening] 11/15/2024 1130 - medication was administered at 13:39 [1:39 in the afternoon] 11/16/2024 1630 - medication was administered at 19:52 [7:52 in the evening] 11/17/2024 0730 - medication was administered at 09:51 [morning] 11/18/2024 0730 - medication was administered at 09:30 [morning] 11/18/2024 1130 - medication was administered at 14:57 [2:57 in the afternoon] 11/19/2024 0730 - medication was administered at 09:38 [morning] 11/19/2024 1130 - medication was administered at 13:29 [1:29 in the afternoon] 11/21/2024 0730 - medication was administered at 10:01 [morning] 11/22/2024 0730 - medication was administered at 09:04 [morning] 11/22/2024 1130 - medication was administered at 13:45 [1:45 in the afternoon] 11/26/2024 0730 - medication was administered at 8:52 [morning] 11/26/2024 1130 - medication was administered at 13:23 [1:23 in the afternoon] 11/27/2024 0730 - medication was administered at 08:53 [morning] 11/27/2024 1130 - medication was administered at 14:29 [2:29 in the afternoon] 11/28/2024 0730 - medication was administered at 09:12 [morning] 11/28/2024 1130 - medication was administered at 14:06 [2:06 in the afternoon] 11/29/2024 0730 - medication was administered at 10:46 [morning] 11/30/2024 0730 - medication was administered at 09:04 [morning] 11/30/2024 1130 - medication was administered at 12:57 [afternoon] 11/30/2024 1630 - medication was administered at 17:58 [5:58 in the afternoon] A review of Resident #1's Progress Notes (PN) from 11/01/2024 to 11/30/2024 showed no documentations that the Resident's attending physician (AP) was notified that the medication was not administered according to the scheduled time on the aforementioned dates. The PN further indicated there was no evidence of harm to Resident #1 from the late administration of medications. In an interview of the Surveyor with Resident #1 in his/her room on 12/20/2024 at 1:49 p.m. [afternoon] regarding his/her medication, Resident #1 stated, they do not always come on time, my medication sucralfate was always late especially in the morning. It has been frequent the last month. In an interview of the Surveyor with Licensed Practical Nurse (LPN #1) on 12/20/24 at 12:28 p.m. [afternoon], LPN #1 stated that for every after medication administration, in the eMAR, the nurse clicked on the Check [sign], then clicked the Save [box] and it will turn green meaning the medication was administered and given to the resident. For every after administration of medication, I tried to make it [box] green right away. In an interview of the Surveyor with Registered Nurse (RN #1) Unit Manager, RN #1 stated that in the eMAR if the medication boxes are yellow that means the medications are due for that time. Once it is green, the nurse had already clicked the Save button which means the medication was administered. RN #1 also stated that if the medications were not administered according to the scheduled time or running late with medications or if the resident refuses, nurse would document that the medication was given late and would call the doctor to notify that the medication was not administered according to the scheduled time. NJAC 8:39-29.2 (d)

Based on interview, record review and document review it was determined that the facility failed to recognize a change in condition and ensure that no delay in treatment occurred, when on 09/23/23, a resident presented with pain accompanied by an externally rotated bruised left lower extremity and the resident was not immediately assessed by a Registered Nurse, and waited over 24 hours to receive an X-ray and was then transferred to the emergency room . This deficient practice occurred for 1 of 1 resident (Resident #257) reviewed for fracture of unknown origin. Resident #257 was diagnosed with an impacted comminuted fracture of the base of the left femoral neck (hip fracture) which required surgery on 09/25/23 for Open Reduction and Internal Fixation (ORIF) of the Left Hip. Refer to 610G The evidence was as follows: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 02/02/24 at 9:58 AM the surveyor, in the presence of the survey team, interviewed the Director of Nursing (DON) regarding reportable events and the Quality Assurance and Performance Improvement process. The surveyor inquired about any recent significant events and the DON informed the surveyor about Resident #257 who sustained a fracture of unknown origin. The surveyor inquired further about what was completed regarding the incident, and the DON stated the resident fell at home and I just did an investigation and then provided the surveyor with a copy of a Reportable Event (a required document to be submitted to the Department of Health). Review of the documents attached to the Reportable Event (RE) included a titled, Investigational Summary and Conclusion, one page of a Care Plan, and copies of fax transmissions dated 09/29/23, to the Department of Health and Ombudsman's office. A review of the RE dated 09/26/23 and Person Reporting: Director of Nursing (DON), revealed: Date of Event: 09/24/23 and Time of Event: 9:42 PM; Was This a Significant Event: Yes. The Type of Incident: Injury; Narrative- 1. Describe the event, to include timeframes/risk factors related to the incident/event (relevant resident diagnosis): Resident was admitted on [DATE] [status post] fall at home. On admission resident c/o [complained of] pain to the left hip, with bruising to left thigh. On 09/22/23, resident continued to c/o [complain of] pain to left hip with PRN [as needed] pain medication given. On 09/23/23, resident's [spouse] alerted staff that resident had a fall at home and asked the nurse to look at patients left lower extremity. Noted purple discoloration to left lateral thigh. Further assessment done and noted leg turned inward. Resident denied pain at that time. MD (Doctor) ordered STAT [immediately] X-Ray. X-ray results showed subcapital fracture of left hip. Resident was sent out to ER [emergency room ] and admitted with left hip fracture. Resident is alert to self with a BIMS [brief interview of mental status] of 6/15 (Severely impaired cognition), past medical history of malnutrition, hypertension, difficulty walking, history of falls, anemia, and syncope and collapse. 3. What interventions were implemented after the incident/event? For example, supervision, resident sent to hospital, CNA (Nurse Aide) suspended. Please describe investigative findings/conclusions: Resident denied pain at the time, STAT (Immediate) X-ray was ordered, Doctor and family aware, X-ray was done, and results showed subcapital fracture of the hip, Resident was sent out to the hospital for further evaluation, Care plan to be updated upon return. There were no Registered Nurse assessments attached to the documentation. The document titled Investigational Summary and Conclusion, revealed: Date of Incident: 09/24/23, Incident Type: Fracture, Description of Event: Resident was admitted on [DATE], s/p [status post] fall at home. Upon admission resident c/o [complained of] pain to left hip with bruising noted to left thigh. On 09/22/23, resident continued to complain of pain to left hip with PRN [as needed] pain meds [medication] given. On 09/23/23, resident's [spouse] alerted staff that resident had a fall at home and asked nurse to look at patients left lower extremity. Noted purple discoloration to left lateral thigh. Further assessment done and noted leg turned inward. Resident denied pain at that time. MD [medical doctor] ordered Stat X-ray. X-ray results showed sub capital fracture of left hip. Resident was sent out to ER and admitted with left hip fracture. The Action: section revealed Resident denied pain at the time, STAT X-ray was ordered, MD and family aware, Resident rested in bed until X-ray results obtained. Follow Up Action: Resident rested in bed until X-ray results were obtained, Resident denied pain at the time, Resident sent out to ER (emergency room ) for further evaluation, Review of nurses notes and any incidents, Review of hospital records and radiology reports. The Conclusion section of the document revealed: Resident was admitted status post falls at home. Upon admission residents left thigh noted with bruising. Hospital record reports that the resident had multiple falls at home and complained of pain to left leg. An X-ray of the left foot left ankle and left knee were obtained while in the hospital and were negative. A doppler was also done in the hospital of the left leg due to resident's pain, that was negative for DVT (deep vein thrombosis a blood clot in the leg). Resident also had a history of left pubic fracture. On 09/23/23, resident's [spouse] asked the staff to assess resident left leg as resident had a fall at home. Upon assessment bruising noted to left thigh as documented on admission, with slight inward rotation of left leg. An X-ray was done that resulted in a left sub-capital fracture of left hip. Resident did not have a fall in our facility and was confirmed by [spouse] and resident that the fall occurred prior to the hospital. Based on the facts gathered and after conducting a comprehensive investigation, facility has concluded that the fracture occurred as a result of the falls sustained at home. Resident continued to have pain to left leg during the hospital stay however an X-ray of the hip was not done. Investigational summary completed by: [DON's name]. There were no statements obtained from any staff that cared for the resident, the spouse, and no documented evidence regarding a fall that caused a fracture prior to admission was included, and as documented in the RE. On 02/02/24 at 11:00 AM, the surveyor reviewed the closed electronic medical record [EMR] and paper record for Resident #257 which revealed the following: Review of the Nursing Comprehensive assessment dated [DATE] at 22:04 [10:04 PM] revealed the resident was admitted from the hospital and required extensive assistance with bed mobility and transfer. C. Skin integrity, Site: left thigh rear, bruising (Details and Comments section was left blank) Length, Width, Depth, Stage: left blank. L. Pain: 37. Pain Management: 1. Received scheduled pain medication regimen, No, 2. Received PRN pain medications or was offered and declined, Yes. 3. Received non-medication intervention for pain, No was checked off. 39. Staff Assessment, Should the Staff Assessment for Pain Be Conducted, No was checked off. Review of the September 2023 Physician Order Summary revealed the following orders: - an order dated 09/23/23 at 16:56 [4:56 PM] with an end date of 09/26/23, Diagnostic X-ray of left hip pain for indication [rule out fracture, order summary, one time only for [rule out fracture for 3 days]. The X-ray report, Date of Service 09/24/23 at 2:28 PM, revealed Study: [left hip pain], Portable left hip 2 views, Impression: Subcapital fracture of the left hip is noted with varus deformity. No dislocation. There was handwritten documentation on the result which revealed called to [primary medical doctor, 09/24/23 at 9:45 PM (approximately 5 hours later). There was no Stat X-ray ordered, as documented in the RE that was submitted to the Department of Health, and as documented as the action taken. -there was no order for bed rest, or any other orders related to positioning, or transfer while X-ray pending. -the Care Plan was reviewed and did not contain any interventions related to caring for the resident when externally rotated and bruised left lower extremity was identified on 09/23/23. - an order dated 09/22/23, Complete a Pain assessment every shift (0=No Pain/Asleep; 1-3= Mild Pain; 4-7 = Moderate Pain; 8-10= Severe pain) every shift. - Acetaminophen (pain medication) Tablet 325 MG (milligrams), Give 2 tablet by mouth every 6 hours as needed for pain 2 Tablets = 650 mg, Order Date-09/21/2023 1916 [7:16 PM]. - Acetaminophen Tablet 325 MG, Give 2 tablet by mouth every 6 hours as needed for mild pain 2 Tablets = 650 mg do not exceed 3 grams per day from all sources. -Order Date-09/22/23 at 12:15. A review of the Medication Administration Record (MAR) and Progress Notes for September 2023 revealed the following: - A Nursing Documentation Progress Note, dated 09/21/23 at 21:21 [9:21 PM] and signed by a Licensed Practical Nurse (LPN) revealed Skin Check completed: No skin injury/wounds were noted. - There was no Acetaminophen documented as administered on 09/21/23. -A Health Status Progress Note, dated 09/22/23 at 12:19 AM, signed by an LPN, revealed, Minimal assist of 1 with ADL's and transfers [Spouse] in for visit this AM, Denies Pain or discomfort at this time, No acute distress noted. This contradicted the Nursing Admission assessment dated one day prior, on 09/21/23, which indicated the resident required extensive assistance with activities of daily living (ADLs). - Acetaminophen was administered on 09/22/23 at 9:33 AM for a Pain Level=4. There was no corresponding progress note regarding the Pain Level=4 and there was no additional Acetaminophen documented as administered on 09/22/23. - The Pain Assessment Every Shift Section in the MAR for 09/22/23 was documented at 0 pain level for all three shifts. This contradicted the MAR when the Acetaminophen was administered on 09/22/23 at 9:33 AM. - A Nursing Documentation Progress Note, dated 09/22/23 at 17:28 [5:28 PM], signed by an LPN revealed Pain Level=0, No Pain. Skin Check completed: No skin injury/wounds(s) were noted. - A Health Status Progress Note, dated 09/22/23 at 21:58 [9:58 PM], signed by a Registered Nurse (RN) revealed Family visit most of this shift. Mood is quiet. Responds appropriately to questions. Denies Needs. Completed care provided for bathing, grooming dressing by one staff. Extensive assistance provided with two staff for bed mobility, Extensive assistance provided by one staff for all surface to surface transfers. Denies Pain. - A Health Status Progress Note, dated 09/23/23 at 6:56 AM, signed by an RN revealed Mood is quiet and appropriate with good affects. Slept X [times] 8 hours. Denies Pain. -The MAR dated 09/23/23 did not reveal any documented Acetaminophen administration for the entire day. - A Health Status Progress Note, dated 09/23/23 at 13:39 [1:39 PM], signed by an LPN revealed Alert and oriented. Clearly verbalizes needs. Denies any pain or discomfort . Heart rate and rhythm regular. Lung sounds clear in all lobes. Respirations even and unlabored . - A Health Status Progress Note, dated 09/23/23 at 16:50 [4:50 PM-3 hours later], also signed by an LPN revealed [Patient] voicing [complaints of] pain [at Left Lower Extremity]. Observed [with] fading blue-green vertical ecchymosis (a bruise) at mid-anterior thigh, a circular purple area of burst vessels, and a circular compartmented area of non-pitting edema at the right upper thigh/groin area, [Left Lower Extremity] and foot area are externally rotated. Spouse is in room visiting at this time and stated that [patient] had fallen at home prior to going to hospital. [New Order] for X-ray of left hip. Positioned in bed for safety and comfort, call bell in reach and spouse at bedside assisting with dinner meal at this time. The was no documented RN assessment, and the surveyor reviewed the Assessment section of the medical record which did not included a documented Registered Nurse (RN) assessment, after the resident presented with the pain, bruise and externally rotated left lower extremity, and no clarification to the documentation regarding the right upper thigh and groin area with edema. -A Health Status Progress Note, dated 09/23/23 at 17:04 PM [5:04 PM] and completed by the LPN revealed spoke with the X-ray company and the tech [technician] will be at the facility to complete X-ray 09/24/23. -A Health Status Progress Note, dated 09/23/23, completed by a RN at 19:02 [7:02 PM] . Mood appropriate with good affects. [Spouse] at bedside. [Spouse] alerted staff about [Resident's] fall at home and asked to look at patient left lower extremity. Noted purple discoloration lateral on thigh, proximal to hip, lower extremity rotate outward laterally and raised area proximal to left groin. Resident denies pain. Supervisor made aware. This was documented 2-hours after the LPN first documented that the spouse had alerted the LPN, who observed the external rotation of the LLE [Lower Left Extremity]. - A Health Status Progress Note, dated 09/24/23 at 11:00 AM, completed by an LPN revealed Received resident alert and oriented. Able to make needs known. [Complained of] generalized pain and administered [as needed] Tylenol. Vital signs stable. Lung sounds clear. Respirations even and unlabored. -The MAR revealed Acetaminophen was administered for a pain level 4 at 8:21 AM and 17:38 [5:38 PM]. -A Health Status Progress Note, dated 09/24/23 at 16:59 [4:59 PM], documented by the LPN revealed . Resident alert with confusion. Skin warm and dry . Minimal assist of 1 with ADL's and transfers. [Spouse] in for visit. Denies pain or discomfort at this time. No acute distress noted. X-ray results pending. - A Health Status Progress Note, dated 09/24/23 at 21:23 [9:23 PM], documented by the LPN revealed Received final report for X-ray of left hip and reads as follows: Subcapital fracture of left hip with various deformities, no dislocation. Placing call out to [Primary Medical Doctor]. -A Health Status Progress Note, dated 09/24/23 at 21:37 [9:37 PM], documented by the LPN revealed spoke with [primary medical doctor and new order] received send to [emergency room ] for fracture of left hip. Spouse notified. 911 notified. -A Physician/NP/PA Progress Note, dated 10/03/223 at 11:58 AM, documented by the NP [Nurse Practitioner with physician] revealed a History of Present Illness. Presented to the emergency room with 10 out of 10 sharp pain that radiates to [his/her] pelvis and left leg Patient was admitted on [DATE] for management of impacted comminuted fracture (a bone broken in at least two places and usually cause by severe trauma) of the base of the left femoral neck. Open reduction internal fixation of the left hip occurred on 09/25/23. Patient was optimized for discharge on 09/27/23. Patient seen today in rehab [rehabilitation]. On 02/01/24 at 11:11 AM, the surveyor interviewed an LPN (LPN #1) who worked on the Sub-Acute unit where Resident #257 resided regarding who would document an order for a Stat X-ray and what would be completed if there was a change in condition. The LPN stated supervisors would enter the X-ray order, and the nurses would be responsible to complete a body assessment and skin check under the assessment task. On 02/02/24 at 1:03 PM, the surveyor conducted a telephone interview, in the presence of the survey team, with the Attending Physician (MD) for Resident #257. The surveyor inquired if there was a delay for over 24 hours in providing an X-ray for a resident who presented with an externally rotated leg what should occur. The MD stated he would expect to be notified by the nurse if an X-ray could not be completed right away then resident should be sent to the hospital and the resident could always return. The MD stated, regarding the external rotation that was observed, if the X-ray cannot be completed within 24 hours, the resident would need to go somewhere where the X-ray would be done emergently. On 02/02/24 at 1:14 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), DON, [NAME] President of Clinical Operations (VPCO) and Corporate Administrator (CA) of the above concerns. On 02/05/24 at 10:10 AM, the survey team conducted an exit interview with the LNHA, DON, VPCO and CA. The DON confirmed that there was no incident report completed. The DON did not provide any orders or documentation to confirm that the resident was on bedrest. The DON did not offer any additional information regarding why the order for the X-ray was not for stat Stat as documented as the action taken in the RE, or any documented RN completed when the change in condition was identified on 09/23/23. The LNHA stated to the survey team, that the fracture did not occur at the facility, after the DON had provided the survey team with copies of hospital records including a copy of a left knee X-ray, dated 09/13/23 with findings of no fracture or dislocation. When asked why there was a delay in providing an X-ray, the LNHA stated, We did an X-ray, yes confirmed it was 30 hours later, but it was done and the fracture was addressed. A review of the following policies revealed: The Resident Evaluation/Assessment Policy, revised 01/2023, The purpose of this procedure is to evaluate or assess the resident for any abnormalities in health status, which provides a bis for the care plan. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the examination. 2. Notify the physician of any abnormalities such as, but not limited to: a. abnormal vital signs; e. wounds or rashes on the resident's skin, f. worsening pain as reported by the resident. 3. Report other information in accordance with facility policy and professional standards of practice. NJAC 8:39-27.1(a)

Based on interview, record review and document review it was determined that the facility failed to ensure that a complete and thorough investigation was conducted for Resident # 257 who sustained a fracture of unknown origin of the left hip. Resident # 257 required an Open Reduction and Internal Fixation (ORIF) of the left hip on 09/25/23 . This deficient practice was identified for 1 of 1 Resident (Resident #257) reviewed for fracture of unknown origin and was evidenced by the following: Refer to 684G On 02/02/24 at 9:58 AM the surveyor, in the presence of the survey team, interviewed the Director of Nursing (DON) regarding reportable events and the Quality Assurance and Performance Improvement process. The surveyor inquired about any recent significant events and the DON informed the surveyor about Resident #257 who sustained a fracture of unknown origin. The surveyor inquired further about what was completed regarding the incident, and the DON stated the resident fell at home and I just did an investigation and then provided the surveyor with a copy of a Reportable Event (a required document to be submitted to the Department of Health). Review of the documents attached to the Reportable Event (RE) included a titled, Investigational Summary and Conclusion, one page of a Care Plan, and copies of fax transmissions dated 09/29/23, to the Department of Health and Ombudsman's office. There were no witness statements or documented interviews provided. The surveyor asked if there was a root cause analysis completed regarding the fracture of unknown origin, and the DON stated, no, that is QAPI (Quality Assurance and Performance Improvement). The surveyor requested the complete investigation for Resident #257's fracture of unknown origin. A review of the RE dated 09/26/23 and Person Reporting: Director of Nursing (DON), revealed: Date of Event: 09/24/23 and Time of Event: 9:42 PM; Was This a Significant Event: Yes. The Type of Incident: Injury; Narrative- Resident was admitted on [DATE] [status post] fall at home. On admission resident c/o [complained of] pain to the left hip, with bruising to left thigh. On 09/22/23, resident continued to c/o [complain of] pain to left hip with PRN [as needed] pain medication given. On 09/23/23, resident's [spouse] alerted staff that resident had a fall at home and asked the nurse to look at patients left lower extremity. Noted purple discoloration to left lateral thigh. Further assessment done and noted left turned inward. Resident denied pain at that time. MD ordered STAT [immediately] X-Ray. X-ray results showed subcapital fracture of left hip. Resident was sent out to ER [emergency room ] and admitted with left hip fracture. Resident is alert to self with a BIMS [brief interview of mental status] of 6/15 (Severely impaired cognition), past medical history of malnutrition, hypertension, difficulty walking, history of falls, anemia, and syncope and collapse. The document titled Investigational Summary and Conclusion, revealed: Date of Incident: 09/24/23, Incident Type: Fracture,: Description of Event: Resident was admitted on [DATE], s/p [status post] fall at home. Upon admission resident c/o [complained of] pain to left hip with bruising noted to left thigh. On 09/22/23, resident continued to complain of pain to left hip with PRN [as needed] pain meds [medication] given. On 09/23/23, resident's [spouse] alerted staff that resident had a fall at home and asked nurse to look at patients left lower extremity. Noted purple discoloration to left lateral thigh. Further assessment done and noted leg turned inward. Resident denied pain at that time. MD [medical doctor] ordered Stat X-ray. X-ray results showed sub capital fracture of left hip. Resident was sent out to ER and admitted with left hip fracture. The Conclusion section of the document revealed: Resident was admitted status post falls at home. Upon admission residents left thigh noted with bruising. Hospital record reports that the resident had multiple falls at home and complained of pain to left leg. An X-ray of the left foot left ankle and left knee were obtained while in the hospital and were negative. A doppler was also done in the hospital of the left leg due to resident's pain, that was negative for DVT (blood clot in the leg). Resident also had a history of left pubic fracture. On 09/23/23, resident's [spouse] asked the staff to assess resident left leg as resident had a fall at home. Upon assessment bruising noted to left thigh as documented on admission, with slight inward rotation of left leg. An X-ray was done that resulted in a left sub-capital fracture of left hip. Resident did not have a fall in our facility and was confirmed by [spouse] and resident that the fall occurred prior to the hospital. Based on the facts gathered and after conducting a comprehensive investigation, facility has concluded that the fracture occurred as a result of the falls sustained at home. Resident continued to have pain to left leg during the hospital stay however an X-ray of the hip was not done. Investigational summary completed by: [DON's name]. There were no statements obtained from any staff that cared for the resident, the spouse, and no documented evidence regarding a fall that caused a fracture prior to admission included, and as documented in the RE. Review of the one page care plan attached to the Reportable Event revealed a Care Plan Focus for High risk for falls dated 09/24/23, Left hip fracture, no fall. On 02/02/24 at 11:00 AM, the surveyor reviewed the closed electronic medical record and paper record for Resident #257 which revealed the following: The Admission Record (an admission summary) revealed the resident had diagnoses which included, but were not limited to; chronic kidney disease Stage- 4 [severe], syncope [fainting] and collapse, and history of falling. Review of the Nursing Comprehensive Assessment, dated 09/21/23 at 22:04 [10:04 PM] revealed the resident was admitted from the hospital and required extensive assistance with bed mobility and transfer. C. Skin integrity, Site: left thigh rear, bruising (Details and Comments section was left blank) Length, Width, Depth, Stage: left blank. L. Pain: 37. Pain Management: 1. Received scheduled pain medication regimen, No, 2. Received PRN pain medications or was offered and declined, Yes. 3. Received non-medication intervention for pain, No was checked off. 39. Staff Assessment, Should the Staff Assessment for Pain Be Conducted, No was checked off. Review of the September 2023 Physician Order Summary revealed the following orders: - an order dated 09/23/23 at 16:56 [4:56 PM] with an end date of 09/26/23 for an X-ray of left hip one time only for to rule out fracture for three days. - an order dated 09/22/23, Complete a Pain assessment every shift (0=No Pain/Asleep; 1-3= Mild Pain; 4-7 = Moderate Pain; 8-10= Severe pain) every shift. - Acetaminophen (pain medication) Tablet 325 MG, Give 2 tablet by mouth every 6 hours as needed for pain 2 Tablets = 650 mg, Order Date-09/21/2023 1916 [7:16 PM]. - Acetaminophen Tablet 325 MG, Give 2 tablet by mouth every 6 hours as needed for mild pain 2 Tablets = 650 mg.do not exceed 3 grams per day from all sources. -Order Date-09/22/23 at 12:15. A review of the Medication Administration Record (MAR) and Progress Notes for September 2023 revealed the following: - A Nursing Documentation Progress Note, dated 09/21/23 at 21:21 [9:21 PM] and signed by a Licensed Practical Nurse (LPN) revealed Skin Check completed: No skin injury/wounds were noted. - There was no Acetaminophen documented as administered on 09/21/23. - A Health Status Progress Note, dated 09/22/23 at 12:19 AM, signed by an LPN, revealed, Minimal assist of 1 with ADL's and transfers, [Spouse] in for visit this AM. Denies Pain or discomfort at this time, No acute distress noted. This contradicted the Nursing Admission assessment dated one day prior, on 09/21/23, which indicated the resident required extensive assistance with activities of daily living (ADLs). - Acetaminophen was administered on 09/22/23 at 9:33 AM for a Pain Level=4. There was no corresponding progress note regarding the Pain Level=4 and there was no additional Acetaminophen documented as administered on 09/22/23. - A Nursing Documentation Progress Note, dated 09/22/23 at 17:28 [5:28 PM], signed by an LPN revealed Pain Level=0, No Pain. Skin Check completed: No skin injury/wounds(s) were noted. - A Health Status Progress Note, dated 09/22/23 at 21:58 [9:58 PM], signed by a Registered Nurse (RN) revealed Family visit most of this shift. Mood is quiet. Responds appropriately to questions. Denies Needs. Completed care provided for bathing, grooming dressing by one staff. Extensive assistance provided with two staff for bed mobility, Extensive assistance provided by one staff for all surface to surface transfers. Denies Pain. - A Health Status Progress Note, dated 09/23/23 at 6:56 AM, signed by an RN revealed Mood is quiet and appropriate with good affects. Slept X [times] 8 hours. Denies Pain. - A Health Status Progress Note, dated 09/23/23 at 13:39 [1:39 PM], signed by an LPN revealed Alert and oriented. Clearly verbalizes needs. Denies any pain or discomfort . Heart rate and rhythm regular. Lung sounds clear in all lobes. Respirations even and unlabored . - A Health Status Progress Note, dated 09/23/23 at 16:50 [4:50 PM], singed by an LPN revealed [Patient] voicing [complaints of] pain [at Left Lower Extremity]. Observed [with] fading blue-green vertical ecchymosis (a bruise) at mid-anterior thigh, a circular purple area of burst vessels, and a circular compartmented area of non-pitting edema at the right upper thigh/groin area, [Left Lower Extremity] and foot area are externally rotated. Spouse is in room visiting at this time and stated that [patient] had fallen at home prior to going to hospital. [New Order] for X-ray of left hip. Positioned in bed for safety and comfort, call bell in reach and spouse at bedside assisting with dinner meal at this time. -A Health Status Progress Note, dated 09/23/23, completed by a RN at 19:02 [7:02 PM] . Mood appropriate with good affects. [Spouse] at bedside. [Spouse] alerted staff about [Resident's] fall at home and asked to look at patient left lower extremity. Noted purple discoloration lateral on thigh, proximal to hip, lower extremity rotate outward laterally and raised area proximal to left groin. Resident denies pain. Supervisor made aware. This was documented 2-hours after the LPN first documented that the spouse had alerted the LPN, who observed the external rotation of the LLE. Review of the Hospital Records revealed the following: - A physician note dated 09/19/23, revealed a urinary tract infection and altered mental status. - An Occupational Treatment Note dated 09/20/23 at 10:40 AM revealed: Patient did not complain of LLE [Left Lower Extremity] pain with movement today. Remains weak. Posterior lean, cognitive deficits and weakness continue to impact safe and independent transfers and ADLs. Continue to recommend rehab at discharge. - A physician note dated 09/20/23 at 11:14 AM which revealed the patient is awake and alert, denies pain. -Registered Nurse progress note dated 09/21/23 at 13:21 revealed: no complaints, denies any abdominal/pelvic pain and medically stable for discharge to sub-acute rehabilitation. On 02/02/24 at 11:34 AM, the surveyor interviewed the DON regarding the RE with the supporting documents that were provided to the surveyor and asked the DON if there was an additional investigation. The DON looked at the RE and stated this is the investigation. The surveyor asked the DON what the components of an investigation included, and the DON stated an incident report and that she had one but did not bring it with her. The surveyor requested for the DON to provide the incident report. On 02/02/24 at 11:39 AM, in the presence of the survey team, the DON stated and confirmed I don't have an incident report for him/her, he/she didn't have any incident, and the spouse told us the resident had a fall at home. The DON confirmed that there were no statements obtained. The surveyor asked what is typically completed regarding an investigation and the DON stated an incident report. On 02/02/24 at 11:43 AM, the [NAME] President of Clinical Operations (VPCO) joined the interview and the surveyor asked if reportable events were investigated and the VPCO stated yes. The DON and VPCO confirmed that there was no investigation, or an incident report completed regarding the fracture of unknown origin for Resident #257. The VPCO stated REs should be investigated. The Accidents and Incidents-Investigating and Reporting Policy, adopted 10/2018 revealed: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: 1. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place, b. The nature of the injury/illness (e.g. bruise, fall, nausea, etc.), c. The circumstance surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e. transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 4. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. R.N. must complete physical assessment of resident of associated incident. On 02/02/24 at 1:14 PM, the surveyor informed the Licensed Nursing Home Administrator LNHA, DON, VPCO and Corporate Administrator of the above concerns. On 02/05/24 at 10:15AM, the DON provided the survey team with copies of hospital records including a copy of a left knee X-ray, dated 09/13/23 with findings of no fracture or dislocation. The facility did not provide any documentation including an investigation with any statements and confirmed that an incident report to determine the causal factor of the fracture of unknown origin was not completed. NJAC 8:39-27.1(a)

Based on interview and document review it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility self-identified areas for improvement and followed the facility policy to ensure the Quality Assurance and Performance Improvement (QAPI) Program reviewed adverse events. This deficient practice occurred for 1 of 1 fractures of unknown origin and was evidenced by the following: Refer to 610G, 761E, 880E On 02/02/24 at 8:55 AM, the surveyor interviewed the LNHA, in the presence of the survey team, regarding what the process was to determine what became a QAPI. The LNHA stated I haven't done anything because I have only been here one month. The LNHA stated he had a meeting with his staff and the surveyor inquired as to what QAPIs were in place already. The LNHA stated that he started looking through the old LNHA's QAPI documents, but he did not get through all of it. The surveyor asked the LNHA how he established what is a high-risk concern and reviewed at QAPI, including adverse events like a reportable event (RE). The LNHA stated he was unaware if adverse events were tracked at the QAPI and that the Director of Nursing would know that information. When asked who was responsible for the QAPI process, the LNHA stated he took responsibility for the QAPI. The surveyor then asked if there was anything that would be considered high risk and he stated, Yes, I am sure that is why they would put it in QAPI. On 02/02/24 at 9:03 AM, the surveyor asked the LNHA to inform the surveyor regarding all the active QAPIs. The LNHA stated his current QAPIs included the following: 1. Housekeeping- mechanical lift pads were getting ripped off and torn. 2. Kitchen- cooks not logging temperature log right before they served the meals. 3. Therapy- orders. 4. Activities- related to picture consents. 5. Infection prevention- regarding water cups in rooms. 6. Material Data Set (MDS)- care plan reviews not signed off. 7. Business office- authorization forms and accounts resident accounts. 8. Nursing- Activity of Daily Living completion logs and completed documentation. On 02/02/24 at 9:10 AM, the LNHA stated he has not yet had a QAPI meeting. The surveyor inquired how the LNHA determine what is brought QAPI, and the LNHA stated maybe a grievance and we see if there are any issues with nursing. On 02/02/24 at 9:15 AM, the DON joined the interview with the LNHA. The surveyor asked the DON what her role was in QAPI process. The DON stated if we see any issues, and the LNHA stated with nursing we would use a root cause analysis and education. The surveyor asked the LNHA what a root cause analysis was and he stated, we do an investigation, in a sense. On 02/02/24 at 9:17 AM, the surveyor asked the DON if the current nursing QAPI plans included the folowing concerns that were identified during the survey: -Hand Hygiene, she responded- no. -Medication Receipt, she responded no. -Anything related to catheter use, she responded no. On 02/02/24 at 9:17 AM, the surveyor asked the DON if she brought any significant events/ or Reportable Events to QAPI and she stated, no. On 02/02/24 at 9:58 AM the surveyor, in the presence of the survey team, interviewed the Director of Nursing (DON) regarding Reportable Events and the Quality Assurance and Performance Improvement process. The surveyor inquired about any recent significant events and the DON informed the surveyor about Resident #257 who sustained a fracture of unknown origin. The surveyor inquired further about what was completed regarding the incident, and the DON stated the resident fell at home and I just did an investigation and then provided the surveyor with a copy of a Reportable Event (a required document for a significant incident that must be submitted to the Department of Health). The surveyor asked the DON if she completed a root cause analysis regarding the fracture of unknown origin. The DON stated, no, that is QAPI, I just did an investigation, and stated the resident fell at home. The Qulaity Assurance and Perforamnce Improvement (QAPI) program-Feedback, Data and Monitoring policy revealed: The QAPI program is based on the collection information obtained from date, self-assessment and systems of feedback. Information is collected, evaluated and monitored by the QAPI committee.Policy Interpretation and Implementation: 1. Information obtained about the quality of care and services delivered to residents is evaluated and monitored by the QAPI committee in order to identify problems that are high risk, high volume or problem prone and to guide decisions regarding opportunities for improvement. 2. The QAPI process focuses on identifying systems and processes that may be problematic and could be contributing to avoidable negative outcomes related to resident care, quality of of life, resident safety, resident choice or resident autonomy, and on making a good faith effort to correct or mitigate these outcomes. The Quality Assurance and performance Improvement (QAPI) Program, Reviewed 5/2023 revealed: The facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI Program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Authority, 3. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory requirements. Systematic Analysis and Systemi Action: Root Cause Analysis is used to fully understand systemic problems, causes of the problems, and implications for change. Teams are formed to identify the root cause and contributing factors of an issue employing the process of the Five Whys of root cause analysis. A thorough understanding of all possible causes or factors impacting the area of focus is critical to identify actions that maybe implemented or systemic changes that my be needed to employ for improvement. NJAC 8:39-27.1(a)

Based on observation, interview, and document review it was determined that the facility failed to ensure a) the kitchen environment and equipment was maintained in a clean and sanitary manner, b) all food items were labeled with a use by date, and c) staff practiced appropriate hand hygiene during meal service to prevent the potential spread of food borne illness. The deficient practice was evidenced by the following: On 01/29/24 at 9:24 AM, the surveyor completed an initial tour of the kitchen with the Food Service Director (FSD) and the Regional Director of Food Service (RDFS) and observed the following: 1. The walk-in refrigerator unit identified as the cold cut box had debris and crumbs on the floor underneath the racks. The surveyor asked when the box was cleaned and the FSD stated, not as often as it should. The door gasket was visibly soiled and ripped. 2. The walk-in freezer unit had ice buildup by the door and the gasket was ripped. 3. The bread rack contained a package of rye bread that was dated with an expiration date of 01/22/24, and there was an unsealed package of hot dog rolls. The FSD discarded the items and stated, that's garbage. 4. A bag of rice and a bag of breadcrumbs were stored inside their bags, in a bin with crumbs on the bottom of the bin. 5. The wall by the affixed knife rack was soiled and two of the knives, identified as clean, were soiled. 6. Clean utensils, were hung directly next to the hand washing sink and the metal spoon and ladle had visible debris on them. On 01/31/24 at 8:00 AM, the surveyor entered the kitchen and observed the meal tray line was in progress. The RDFS was on the tray line and was serving the hot food items at that time, with the FSD opposite of the RDFS preparing the trays. During the observation, the surveyor observed that pancakes were being served and the surveyor asked the RDFS what the hot food temperatures should be when the food reached the resident. The RDFS stated , no less than 145 degrees [Fahrenheit]. The surveyor then continued to observe the ongoing tray preparation on the tray line. The RDFS was observed placing oatmeal by a ladle, utilizing his gloved hands, into a Styrofoam cup and then placed it on a plate. Then, without using a utensil, or first removing his gloves and performing hand hygiene, he proceeded to pick up two pancakes with his gloved hands, and then placed them on the resident meal plate. The surveyor observed that there was no serving utensils inside the pan of pancakes. The RDFS then touched a pink towel that was in front of the steam table with his gloved hands, and then turned around and opened the refrigeration unit that was behind him and used his gloved hand and removed an item. The RDFS, without first performing hand hygiene, continued to pick up two more pancakes with the same gloved hands. The RDFS then turned around and opened the hot box that was behind him, using the handle with the same gloved hands, and removed an omelet, closed the hot box, and then placed the omelet on a resident meal plate. Then, without performing hand hygiene, or removing the gloves, the RDFS picked up two more pancakes with his gloved hands and placed them on a resident meal plate. At 8:04 AM, the surveyor asked the RDFS if he should go back and forth and open and close doors and pick up pancakes with the same gloved hands, and he acknowledged he should not. The surveyor asked the FSD, who also observed the RDFS utilizing gloved hands to complete different tasks, then pick up food with the same gloved hands and plate the food. The FSD stated that food should not be touched with gloved hands. On 02/02/24 at 8:42 AM, in the presence of the survey team, the surveyor conducted an interview with the Regional Dietitian (RD). The surveyor informed the RD of the observations regarding the meal service that occurred on 01/31/24. The surveyor asked the RD if it was acceptable to touch foods directly with gloved hands, and then touch other non food items and continue to touch food with the same gloved hands. The RD stated no, that is not acceptable and the staff was trained to not do that. The Handwashing/Hand Hygiene Policy, Adopted 11/2018 revealed This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The Cleaning Policy, Updated 01/2023 revealed it is the responsibility of all staff to maintain sanitary standards in their areas and where needed per food service director. Fod Service Director: Execute daily sanitation audit to find deficient areas in kitchen and assign daily tasks to staff. Audit all staff tools from previous day. The Dining Service Inc., Dating Policy dated 01/01/2024 revealed Follow manufacturers expiration date on all un-opened products. All fresh and frozen foods must be dated with date it was received into the kitchen. NJAC 8:38-17.2(g)

Based on observation, interview, and document review it was determined that the facility failed to ensure meals were served at a palatable temperature for 6 of 6 residents who attended a resident council meeting, and on 2 of 3 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 01/30/24 at 11:04 AM, the surveyor conducted a resident council meeting with six residents. The surveyor inquired about the meals served and 6/6 residents interviewed stated the [hot food] was always served cold and especially the coffee. On 01/31/24 at 7:30 AM, surveyor #1 observed the meal truck enter Unit 3. The first meal tray was passed at 7:31 AM, and the last meal tray was passed at 7:49 AM. At that time, the surveyor removed the last meal tray and completed a test meal observation, in the presence of the Unit Manager Nurse, with the following recorded temperatures: Oatmeal: 136 degrees Farenheight (F) Sausage: *112 F 2 Pancakes: *120 F 4-ounce Orange Juice: *51 F 8-ounce Low Fat Milk: *56 F Coffee: *112 F On 01/31/24 at 8:40 AM, surveyor #2 observed the meal cart arrive on Unit 2 and the last tray was served at 8:50 AM. In the presence of a Certified Nurse Aide, surveyor #2 recorded the following food temperatures: Oatmeal: 148.5 F 2 Pancakes: *114.3 F Sausage: *111.7 F Coffee: 154 F 4- ounce Orange Juice: 42 F *Items did not meet Temperature Standards per the Test Tray form. On 01/31/24 at 8:00 AM, the surveyor entered the kitchen and observed the meal tray line was in progress. The RDFS was on the tray line and was serving the hot food items, with the FSD opposite of the RDFS preparing the trays. During the observation, the surveyor observed that pancakes were being served. The surveyor asked the RDFS what the hot food temperatures should be when the food reached the resident and he stated, no less than 145 degrees [Fahrenheit], and the temperatures were documented on the Test Tray form. On 01/31/24 at 8:06 AM, the surveyor reviewed the Test Tray form which revealed Temperature Standards Hot Entree: 130 F, Hot Beverage: 150 F, Juice: 50 F, Cold Beverage 45 F. On 02/01/24 at 12:32 PM, surveyor #1 interviewed the RDFS regarding the Temperature Standards on the Test Tray form. The RDFS confirmed to surveyor #1 that the Temperature Standards were the temperatures that the foods should be when the meals were served to the residents. The Test meal/Tray Audit Policy, dated 01/01/2024 revealed A test meal or tray audit will be conducted as deemed necessary to ensure proper temperatures and acceptable quality of all foods served. NJAC 8:39-17.4(a)2

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure resident specific prescription medications were stored securely. This deficient practice was identified for 1 of 2 units (Unit 2) observed and was evidenced by the following: On 01/31/24 at 6:13 AM, the surveyor observed two nurses on Unit 2 working at their medication carts. One nurse was at the high end of the hall, and the second nurse was at the low end of the hall. Both nurses were observed actively working at their nursing carts. The surveyor walked down toward the low end of the hall, toward the middle of the unit and observed a third nursing medication cart. The third nursing medication cart was placed up against a wall across from the nursing desk. The surveyor observed six bingo cards (a pop out pill dispensing system) with resident names printed on them, with prescription medication inside the bingo cards, a container with a resident name printed on it that contained prescription eye drops, and a prescription inhaler system with a resident name on the label. The surveyor remained at the nursing desk and observed two housekeeping staff walking past the accessible, unsecured prescription medications. On 01/13/24 at 6:35 AM, one of the nurses who was identified as an agency Licensed Practical Nurse (LPN) approached the third medication cart with the unsecured prescription medications on top. At that time, the surveyor inquired why the medications were sitting on top of the medication cart. The LPN stated, logically they [the prescription medications] should be put away, but I did not sign for their delivery. The LPN opened the bottom drawer of the third medication cart and placed all the prescription medications that had been delivered inside the drawer and then locked the medication cart. On 01/31/24 at 6:37 AM, the second nurse who was identified as the facility Registered Nurse (RN) stated she had signed for the delivery of those medications but did not secure them because the LPN had the keys to the third medication cart. The RN stated that the medications should have been secured when they were delivered, and not left on top of the medication cart. On 01/31/24 at 8:38 AM, the Director of Nursing (DON) and the Unit 2 LPN Unit Manager (LPN/UM) were made aware of the prescription medications being unsecured and out of direct sight of the nurses for 22 minutes, and staff observed walking passed the medication on the unit. At that time, the DON stated the process was that medications would be delivered, and the nurses would be responsible to reconcile the medications against the delivery sheet from the pharmacy. She further stated that the medications would be given to the nurse who was responsible for that resident's medications in the medication cart. The DON stated that medications left unsecured on top of a medication cart was unacceptable because anyone could have taken them. On 01/31/24 at 9:14 AM, the 7:00 AM to 3:00 PM, RN on Unit 2 stated the process for prescription medication deliveries was that the nurse who accepted the delivery would reconcile the medications with the pharmacy delivery sheet. The medications would be delivered to their respective medication carts depending on the resident, and taken care of right away. Narcotics would require the signature of two nurses. The RN stated that prescription medication should never be left unattended because anyone, even residents, could take them. On 01/31/24 at 9:25 AM, the pharmacy consultant in the presence of the survey team, stated the nurses should have eyes on it [the delivered prescription medications] at all times. She further stated that all medications should be stored behind a lock, it is a law and that there could be residents who could swallow the unattended medications. The pharmacy consultant stated that medications were easy enough to pop out of the bingo cards. A review of the facility provided Packing Slip Proof of Delivery, dated 1/31/24, revealed that the agency LPN had signed for the pharmacy delivered medications at 5:28 AM. A review of the facility provided, Staff Nurse job description undated, included but was not limited to; performs all tasks in accordance with established policies and procedures. Ensures a safe environment. A review of the facility provided, Administering Medications policy updated 1/2023, included but was not limited to; 16. the medication cart is kept closed and locked when out of sight of the nurse. No medications are kept on top of the cart. The cart must be clearly visible must be inaccessible to residents or others passing by. A review of the facility provided, Storage of Medications policy, updated 1/2023, included but was not limited to; heading: store all drugs and biologicals in a safe, secure, and orderly manner. Interpretation and Implementation: 1 Stored in locked compartments Only persons authorized to prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage . in a clean, safe, and sanitary manner. 6. Compartments containing drugs and biologicals are locked when not in use. NJAC 8:39-27.1, 29.3(h)

Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to ensure all residents had a call bell available and within reach to alert staff for assistance. This deficient practice was identified for 2 of 25 residents reviewed for call bells (Resident 100 and Resident #6) on 2 of 3 resident units (Unit #1 and #2) and was evidenced by the following: On 01/29/24 at 11:40 AM, while in the hallway on the Unit #1, Surveyor #1 heard a staff member calling on the nurse to assist with Resident #106. The surveyor followed the nurse and observed Resident #106 sitting on a low bed and had attempted to get out of the bed unassisted. The resident stated that he/she needed to go the bathroom. The surveyor did not observe a call bell located near the resident. On 01/29/24 at 12:11 PM, Surveyor #1 observed the resident in a recliner chair at the nurse's station. The surveyor attempted to interview the resident. The resident stated,I need to go to sleep and you should go to sleep. The surveyor returned to the room and observed the call bell was behind the dresser at the adjacent corner of the room. On 01/30/24 at 8:20 AM, Surveyor #1 observed Resident #100 in bed. The bed was in a low position with a floor mat on the right side of the bed. The call bell was noted in the same position, behind the dresser at the adjacent corner of the room. The call light was not accessible to the resident. On 01/30/24 at 9:00 AM, Surveyor #1 entered the room with the Licensed Practical Nurse (LPN). Surveyor #1 observed Resident #100 was awake in bed, and there was no call bell attached to the wall or within reach of the resident. The surveyor inquired to the LPN if she could show and activate the call bell for Resident #100. The nurse could not locate the call bell. The call bell was not attached to the bed. The nurse looked into the room and reached for the call light that was behind the dresser in the room. The nurse stated that the call light should be accessible and attached to the resident's blanket. On 01/30/24 at 9:12 AM, Surveyor #1 asked the Unit # 1 Licensed Practical Nurse /Unit Manager (LPN/UM) how the resident's care was communicated to the direct care staff. The LPN/UM revealed that in the morning the nurses would give report to the Certified Nursing Assistant (CNA). The surveyor then inquired regarding Resident #100's care. The LPN/UM stated that Resident #100 was confused at times, had poor safety awareness, and that all needs must be anticipated. The LPN/UM stated that Resident #100 can activate the call bell and the call bell should be within reach. On 01/30/24 at 11:19 AM, Surveyor #1 reviewed Resident #100's medical record. The Admission Record revealed that Resident #100 was admitted to the facility with diagnoses which included but were not limited to: metabolic encephalopathy, difficulty in walking and muscle weakness. The Admission Minimum Data Set (MDS) an assessment tool used by the facility to prioritize care dated 01/15/24, reflected that Resident #100 had a moderately impaired cognition and scored 08/15 on the Brief Interview for Mental Status (BIMS). Review of Progress Notes dated 01/14/24 at 15:06 (3:06 PM), reflected that Resident #100 was alert with confusion and required substantial/maximum assistance of 2 persons for bed mobility. The comprehensive Care Plan dated 01/12/24 had a focus area for falls related to limited mobility. One of the goal was to place call light within reach at all times. Surveyor #1 observed Resident #100 in bed on 01/29/24 at 11:40 AM, 01/30/24 at 8:20 AM, and again at 9:00 AM. The call bell was not accessible to the resident. 38079 On 01/29/24 at 10:07 AM, Surveyor #2 was interviewing Resident #6 in his/her room. Resident #6 was lying in bed with the head of the bed elevated. Resident #6 had a supplement drink on the over bed table. The surveyor asked if he/she needed to use the call bell to request assistance with the supplement drink. Resident #6 stated, look behind me. Resident #6 next stated, I can't use the call bell because I haven't had one in a while. Resident #6 was unable to say how long his/her call bell was missing but stated that he/she relied on asking the roommate to call when needed. A review of the Admission Record revealed Resident #6 had diagnoses which included but were not limited to; hypotension (low blood pressure), chronic kidney disease, dementia, congestive heart failure, and unsteadiness on feet. A review of the Annual Minimum Data Set (MDS) an assessment tool to facilitate resident care dated 12/23/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 10/15 which indicated Resident #6 had moderate cognitive impairment. Section GG - Functional Abilities and Goals revealed that Resident #6 was dependent on staff for toileting, shower/bathing, dressing, and personal hygiene. A review of the resident centered on-going care plan included but was not limited to; a focus area of ADL (Activities of Daily Living) self-care deficit related to limited mobility date imitated 6/22/18. Goals included ADL care needs will be anticipated and met. Interventions included dependent of 1 staff with showering; extensive assistance for bed mobility; extensive assist by 1 staff to dress; minimal assistance by 1 staff for oral care tasks; extensive assist by 1 staff for toileting; extensive assist by 1 staff to move between surfaces and as necessary; and encourage to use bell to call for assistance. On 01/29/24 at 10:09 AM, Surveyor #2 went to the Unit #2 nurse's desk and asked the Liscensed Practical Nurse Unit Manager (LPN/UM) to accompany the surveyor to Resident #6's room. The LPN/UM looked around the room and acknowledged there was no call bell available for Resident #6. The LPN/UM then stated it was important for all residents to have a call bell and that the call bell be within reach because the call bell was a resident's lifeline. At that time, Resident #6 stated to the LPN/UM and surveyor that he/she has had to rely on their roommate to call for help. On 02/02/24 at 9:47 AM, Surveyor #2 observed Resident #6 in bed. The surveyor did not observe a call bell. The surveyor asked Resident #6 if he/she had his/her call bell and the resident shook his/her head no. The surveyor looked for the call bell and observed it at the top of the bed above the residents pillow and was out of reach of the resident. On 02/02/24 at 9:49 AM, the second unit LPN/UM accompanied Surveyor #2 to the resident's room and acknowledged the call bell was not in reach of the resident. A review of the facility provided, Certified Nursing Assistant job description undated, included but was not limited to; answer resident calls promptly. Ensure a safe environment. A review of the facility provided, Staff Nurse job description undated, included but was not limited to; make (at least daily) rounds to evaluate and observe the resident's physical and emotional status and to ensure continuing quality of care. Answers call lights promptly. Ensures a safe environment. Ensures that resident who are unable to call for help are checked frequently. A review of the facility provided, Call Lights procedure updated 01/2023, included but was not limited to; Purpose: the light and/or sound system to alert staff to patient needs. Equipment: bedside call light with cord. Procedure: 6. Always position call light conveniently for use and within reach of the resident. 8. Check lights when providing care to ensure that cord length is appropriate, and that light is in working order. Report defective call lights promptly . NJAC 8:39-31.8 (9)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to a.) properly don (put on) a Personal Protective Equipment (PPE) gown used to mitigate the spread of infection for Resident #306, 1 of 4 residents reviewed for Transmission Based Precautions (TBP) , b.) maintain appropriate infection control practices for 2 residents (Resident #106 and #306) with an indwelling urinary catheter, and c.) to perform appropriate hand hygiene during meal service on 1 of 3 units (Unit 3) for two meals. This deficient practice was evidenced by the following: a.) On 01/30/24 at 8:21 AM, Surveyor #1 observed a staff member outside of Resident #306's room. The surveyor observed signage posted at the door for enhanced barrier precautions which included but was not limited to; providers and staff must also: wear gloves and gown for the following high-contact resident care activities which included dressing and transferring. The surveyor observed a bin full of available PPE. At that time, a staff member approached Resident #306's room. The staff member was wearing a surgical mask and donned a PPE gown. The staff member failed to secure the PPE gown with the ties around her back. The staff member entered the room and explained to the resident she was there to help her get dressed and work with her. The staff member was in direct contact with the resident, the resident's bed, and kneeled down with the PPE gown freely flowing open and in direct contact with the resident and the resident's environment. At 01/30/24 at 8:28 AM, Resident #306's Licensed Practical Nurse (LPN) was in the hall outside of the resident's room. The LPN stated that the resident was on precautions because he/she had a nephrostomy (a tube into the kidney to facilitate removal of urine), a urinary tract infection, and sepsis. The LPN stated that to provide care, staff were to apply gloves and PPE. When asked about how to apply the PPE gown, the LPN replied to put the hole over the head, slide arms through, and tie it in the back in order to cover the entire body. She stated it needed to cover the staff completely in order to prevent infection on the staff and being transferred to other residents. The LPN knocked on the door, opened the door and was able to acknowledge that the staff member did not wear the PPE gown properly to prevent the spread of infection. The LPN and surveyor observed the staff member in direct contact with the resident and assisting the resident with dressing. The resident had his/her hands in the air and the Director of Therapy was actively assisting him/her putting on a top. On 01/30/24 at 8:34 AM, the staff member exited the room and was interviewed at that time. The staff member identified herself as the Director of Therapy. She stated the resident was on TBP because of an infection in the urine. She further stated that she was aware she had her PPE gown on incorrectly and that she just forgot. She stated that the importance of wearing the PPE was to ensure her whole body was covered to prevent infection. A review of the Admission Record revealed that Resident #306 was recently admitted with diagnoses which included but were not limited to; urinary tract infection; sepsis due to Escherichia coli (E. coli a bacteria that can cause infection and can be spread easily), and anxiety. A review of the Order Summary Report revealed an order dated 1/28/24, Skilled PT [physical therapy] eval [evaluation] & tx [treatment] 4-6 x/wk [times a week] x 41 days or as tolerated for therapeutic exercise, therapeutic activities, neuromuscular re-education, gait training, bed mob [mobility]/transfer training, pt.[patient]/caregiver education, d/c [discharge] planning. A review of the resident-centered on-going care plan included but was not limited to; a focus area of ADL [activities of daily living] deficit related to impaired balance, limited mobility with interventions which included staff assistance which included bathing and dressing. A focus area requires enhanced barrier precautions related to (indwelling medical device, infection, or colonization with MDRO [multi drug resistant organism]. Interventions included but were not limited to; clear signage on the door indicating the type of precautions and required PPE. for Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. A review of the Physical Therapy Summary of Daily Skilled Services, dated 01/30/24, included but was not limited to; BLE [bilateral lower extremities] there [therapy] ex [exercise] for hip flex [flexion], 3 x 10 res [repetitions]. Dynamic standing balance. Gait training. Skilled interventions focused on transfer, training to increase functional task, performance, strengthening activities to increase functional performance . intermittent tactile cues/ intermittent physical assistance. Transfers sit to stand with minimum A [assistance]. On 01/30/24 at 9:22 AM, the LPN Infection Preventionist (LPN/IP) stated that the Director of Therapy had been educated in donning and doffing (removing) PPE. The LPN/IP stated that it was important to wear PPE correctly to protect the staff members clothes and prevent them from transmitting infection to other residents. A review of the facility provided In-Service, Droplet Precautions, Contact Precautions, EBP (Enhanced Barrier Precaution), hand hygiene and PPE Review, dated 12/26/23, included the Director of Therapy had attended and was educated. The education material included but was not limited to; clinical competency validation critical elements: Gowning 5. Pull gown on, making sure it completely covers clothing/torso. If it does not, use 2 gowns. Don the first gown with opening to the front. Use the second gown over the first, with opening to the back. The facility included the competency that the Director of Therapy had demonstrated and passed, dated 12/26/23. A review of the facility provided, Enhanced Barrier Precautions Policy and Procedure, revised 7/22/22, included but was not limited to; Purpose: the implementation of EBP will reduce the transmission of resistant organism by employing targeted gown and glove use during high contact resident care activities. Policy: EBP will be implemented for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . Nursing home residents with Indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. 27193 b.) On 01/29/24 at 10:25 AM, Surveyor #2 observed Resident #106 sitting in a wheelchair in the room with a urinary drainage leg bag attached to the resident's right leg. On 01/29/24 at 11:01 AM, Surveyor #2 returned to the room and found the resident was awake and alert and informed the surveyor he/she just returned from Physical Therapy (PT) and was tired. The surveyor asked for the resident's consent to check the bathroom. The surveyor then observed the Foley urinary catheter drainage bag stored in a plastic bag hung on the rail in the bathroom. The Foley urinary catheter drainage port was not capped. On 01/31/24 at 12:45 PM, Surveyor #2 entered the room and observed Resident #106 in bed. Surveyor #2 observed the Foley urinary catheter drainage bag inside a dignity bag rested in direct contact on the floor. The surveyor left the room and informed the LPN who was at the nurses station of the observation. The LPN went to the room, adjusted the bed and exited the room. On 01/31/24 at 1:15 PM, during an interview with the LPN, the LPN stated that the dignity bag should not be rested in direct contact on the floor to prevent infection. On 02/01/24 at 11:30 AM, Surveyor #2 observed the resident in bed. The urinary drainage dignity bag was noted in direct contact with the floor. The surveyor escorted the LPN to the room and she confirmed the surveyor's observations and repositioned the bed. A review of the Admission Face Sheet (a summary assessment) reflected that Resident #106 was admitted to the facility with diagnoses which included but were not limited to; malignant neoplasm of bilateral ovaries, difficulty in walking and urinary retention. The Admission Minimum Data Set (MDS) dated [DATE], reflected that Resident #106 had intact cognition. Resident #106 scored 15/15 on the Brief Interview for Mental Status (BIMS). The Comprehensive Care Plan dated 01/19/24, reflected that Resident #106 had an indwelling Foley urinary catheter related to urinary retention. The Order Summary Report dated 02/01/24, reflected an order to render indwelling Foley Catheter Care every shift and as needed. An interview with the LPN on 01/29/24 at 11:40 AM, revealed that the Certified Nursing Assistant (CNAs) were responsible to provide catheter care to the residents. The LPN stated, the CNAs would empty the drainage bag, and recorded and reported the urinary output to the nurse. The LPN added that during the day the CNAs would switch the Foley urinary catheter drainage bag to a leg bag to facilitate therapy. On 02/01/24 11:50 AM, Surveyor #2 interviewed the CNA regarding the storage of the Foley urinary catheter drainage bag. The CNA stated that the drainage bag should be capped to prevent infection. A review of the Progress Notes dated 01/16/24 timed 11:36 PM, revealed that the Foley urinary catheter tubing was noted with viscous white sediment. The physician was informed and ordered a urine analysis and culture and sensitivity to rule out a urinary tract infection. The urine specimen collected on 01/16/23 was positive for E.coli ( Escherichia coli) a bacteria which normally live in the intestines, and (Proteus Mirabilis) a gram-negative organism. Resident #106 was diagnosed with a Urinary Tract Infection (UTI). A review of the Admission Face Sheet revealed that Resident #306 was admitted to the facility with diagnoses which included but were not limited to: Urinary Tract infection and sepsis due to to E.coli. The Admission Care Plan dated 01/27/24, reflected that Resident #306 had a focus for Urinary Tract Infection related to E coli. The goal was the urinary tract infection will be resolved without complications. Interventions included: Encourage adequate fluid intake, monitor vital signs, obtain and monitor lab/diagnostic work as ordered . Resident #306 had also a focus for enhanced barrier precautions related to indwelling medical device: Nephrostomy tube. The goal was that Resident #306 will have no ill effects related to the enhanced barrier precautions. Interventions included: Clear signage must be posted on the door or wall outside of the resident room. Educate the resident /family and care giver on the importance of handwashing. The care plan did not provide the direct care staff directives regarding storage of the Foley catheter drainage bag to prevent infection. On 01/30/24 at 9:30 AM, Surveyor #2 observed Resident #306 sitting in the room with urinary collection leg bag attached to the right leg. The surveyor asked the resident if she could checked the bathroom. The resident agreed. The surveyor went to the bathroom and observed the Foley urinary catheter drainage bag stored in a plastic bag hung on the rail in the bathroom. The drainage port was not capped. On 01/31/24 at 9:40 AM, Surveyor #2 observed Resident #306 sitting in a wheelchair in the room with the urinary collection leg bag secured to the right leg. The surveyor went to the bathroom and observed the Foley catheter drainage bag stored in a plastic bag hung on the rail in the bathroom. The drainage port was not capped. The surveyor left the room and escorted the LPN to the bathroom. The LPN donned gloves and retrieved the Foley Catheter drainage bag from the plastic bag in the bathroom. The Foley catheter drainage bag was noted with cloudy residual urine, the bag dated 01/27, and the drainage port was not capped. The nurse stated that the bag should be rinsed and capped to prevent infection. On 01/31/24 at 9:52 AM, Surveyor #2 interviewed the CNA who cared for the resident. She acknowledged that she cared for Resident #306 that morning and disposed of the drainage bag in the receptacle bin. The surveyor went to the bathroom with the CNA and we both observed the Foley urinary catheter drainage bag stored in the plastic bag hung on the rail in the bathroom. When asked regarding catheter care, the CNA demonstrated to the surveyor how she switched the Foley urinary catheter drainage bag to the leg bag during care. She did not acknowledged that the drainage port needed to be disinfected before being connected. On 01/31/24 at 10:12 AM, Surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM) regarding Foley urinary catheter care. The LPN/UM revealed that the CNAs were to clean and observe the area around the catheter. The LPN/UM added that the residents would have the Foley urinary catheter drainage bag while in bed, but the leg urinary bag was being used during the day when the resident was up and in therapy. The Foley urinary catheter drainage bag was changed weekly and as needed. The CNAs were to wash their hands, explain the procedure to the resident, don gloves, cleanse the port with an alcohol swab and switch over to the leg urinary bag. The Foley urinary catheter drainage bag was to be rinsed of any residual urine, stored in a plastic bag in the bathroom with the drainage port capped. The LPN/UM stated that she was aware of the concerns, and she would consult with the Infection Preventionist (IP) and identify when the last in-service on Foley urinary catheter care was done. On 01/31/24 at 11:16 AM, the Director of Nursing (DON) provided an in-service sign-in sheet for the Foley urinary catheter policy and procedure dated 11/08/23. Both CNAs involved attended the in-service education. On 02/02/24, Surveyor #2 reviewed the facility's Policy/Procedure: Catheter Care, Urinary with a revision date of 08/2022 updated 1/2023, which included but was not limited to; Purpose The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Infection Control Use aseptic technique when handling or manipulating the drainage system Be sure the catheter tubing and drainage bag are kept off the floor. Cleaning drainage bags: Disconnect the drainage bag from the catheter; replace with a clean bag. Use a soft, plastic squirt bottle to rinse the used bag with tap water and drain. Cleanse the drainage bag with water' Drain the water, and allow the bag to air dry with the clam open. Use bleach that is not scented or concentrated. When using a water, use gloves, aprons, and goggles to protect from fumes and irritation caused by contact. After cleansing, air-dry the bag. After cleaning, cap drainage bag tubing between uses and disinfect the end of the tubing with alcohol before reconnecting it to the catheter. On 02/02/2024 at 1:14 PM, the survey team met with the administrative staff and informed them of the findings. On 02/05/24, the facility provided in-service education done on Foley urinary catheter care. No additional information was provided. Surveyor: Nocks, [NAME] L. c. On 01/31/24 from 7:31 AM to 7:49 AM, the surveyor observed the breakfast meal delivery on Unit 3. The meal trays were distributed from a meal cart and the surveyor observed two Certified Nurse Aides (CNA #1 and #2) distribute meals. CNA #1 was observed, wearing gloves in the hallway, then removed a meal tray from the meal cart. She then brought the meal tray to room [ROOM NUMBER], and proceeded to set the meal tray up for the resident, then without first removing her gloves and performing hand hygiene, she repeated the same observation in room [ROOM NUMBER], and #307 wearing the same gloves. The surveyeyor then interviewed CNA #1 regarding what should be done between the meal trays and setting up the residents. CNA #1 stated she knows she needed to use hand hygine (HH), howerver, there was no HH available in the hallway for the staff to use. The surveyor then interviewed the Unit Manager (UM) regarding the surveyor's observations. The UM stated that they should have had hand sanitizer on them and showed the surveyor a bottle that she had in her pocket, and stated hand sanitizer was also located behind the nurses station. On 01/31/24 at 12:09 PM, during the lunch meal service in the Unit 3, activities room, the surveyor observed six staff members deliver lunch trays to 13 residents without performing hand hygiene between residents. The surveyor did not observe any hand gel readily available to the staff in the activities room. The surveyor observed a CNA, using hand hold assistance, ambulated an unsampled resident and assisted the resident to a chair at a table. CNA#1 then went to the food cart and obtained the resident's lunch tray, placed it in front of the resident, removed the plate and juices from the tray and placed them on the table. CNA#1 returned the tray to the food cart. CNA#1 did not perform hand hygiene before proceeding to assist another resident. The surveyor observed CNA#2 assist an unsampled resident by adjusting his/her legs onto the wheelchair leg rests. CNA #2 then assisted another resident set up their juice on the table without performing hand hygiene between residents. On 01/31/24 at 12:17 PM, the surveyor interviewed an Activities Aide (AA) who stated that during lunch meal he would help pass out the lunch trays, make sure the diets are correct and that it was the correct lunch tray for the right resident. When asked if hand hygiene should be performed between residents, the AA stated I did not do it today because we were serving fast. I normally do but not today. On 01/31/24 at 12:21 PM, the surveyor interviewed CNA #1 who stated you're supposed to use hand hygiene between residents when serving trays but we don't have any. I know the rules but we don't have hand gel. The Handwashing/Hand Hygiene Policy, Adopted 11/2018 revealed This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. NJAC NJAC 8:39-19.4 (a) (1)(5) 31654

Complaint #169841 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain professional standards of nursing practice by failing to: a.) follow a physician order for weights for 1 of 4 residents (Resident #95) reviewed for nutrition, and b.) administer physician prescribed medications and document physician notification for 1 of 4 closed records (Resident # 256) reviewed. The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. a.) On 01/29/24 at 10:34 AM, during an interview with Surveyor #1 , Resident #95 was observed watching television in his/her room. The resident stated he/she had pancakes with bacon, milk, and coffee for breakfast. The surveyor observed an empty meal tray inside the room and on top of the nightstand. During an observation on 01/31/24 at 12:25 PM, the surveyor observed Resident #95 in the main dining area of Unit 3 and was sitting with peers having lunch. The lunch meal tray was observed to have beef goulash over noodles, mixed vegetables, and cake. The resident had consumed more than 50% of the meal at that time. A review of the medical record for Resident # 95 revealed that Resident #95 had a physician order dated 9/25/23 as follows: Weekly Weight, every day shift every Monday for monitoring document in weight binder. A review of the documented weights in the Electronic Medical Record (EMR) revealed the following weights: -9/26/2023 223.0 lbs (pounds) -10/10/2023 205.0 lbs -10/17/2023 102.2 lbs -10/25/2023 199.6 lbs -11/1/2023 200.0 lbs -12/1/2023 213 lbs - 12/5/23 210 lbs -1/2/2023 206.2 lbs The facility failed to follow the physician order written on 9/25/23 to obtain weekly weights for Resident #95. The facility documented 1 out of 4 weeks for the month of November 2023, 1 out of 4 weeks for the month of December 2023 and 1 out of 4 weeks in the month of January 2024. On 02/02/24 at 9:50 AM, surveyor interviewed the Registered Dietitian (RD). The RD stated that it was the responsibility of the Certified Nursing Assistant (CNA) and nurses to obtain the weights of the residents and log them into the weight binder. The RD stated after the weekly weights were documented in the weight binder by the nurses it was the RD's responsibility to transcribe them into the EMR. The RD also stated that the weekly weights needed to be logged in the EMR on Fridays every week, by the end of the day. The RD stated it was important to have the weights readily accessible in the EMR because they were used to monitor progress and make clinical judgements. The RD confirmed that the weekly weights should have been documented in the EMR for resident #95. During an interview with the surveyor on 02/02/24 at 10:13 AM, the Unit Manager Licensed Practical Nurse (UMLPN) for Unit 3 stated that resident had an order for weekly weights since 9/25/23. The UMLPN confirmed that the weekly weights were not documented in the EMR and they should have been. The UMLPN stated it is important to monitor for weekly weights to ensure the resident gets the proper nutrition. A review of the facility provided, Weight Assessment and Intervention policy interpretation and implementation updated 11/2023, included but was not limited to; #2. Weights will be recorded in the resident's electronic medical record, #8. It is the responsibility of the nursing to obtain and enter weights upon admission/readmission into the facility and also to obtain and enter daily weights as ordered by the MD (Medical Doctor). A review of the facility provided job description of the Dietitian, undated, included but was not limited to; Duties and Responsibilities: -Provides and maintains accurate documentation -Plans, implements, and reports on performance improvement activities and directs quality assurance audits -Ensures compliance with state and other regulatory agencies. b.) A review of the closed medical record for Resident #256 revealed diagnoses which included but were not limited to; acute myocardial infarction (tissue death of the heart muscle caused by a lack of oxygen), acute respiratory failure with hypoxia (lack of oxygen), hyperlipidemia (elevated fats in the blood), and pain. A review of the first assessment Minimum Data Set (MDS) an assessment tool used to facilitate resident care, dated 05/02/23, included but was not limited to; a Brief Interview for Mental Status of 15/15 which indicated the resident was cognitively intact. A review of the resident-centered on-going care plan included but was not limited to; focus area has constipation related to decreased mobility, pain with interventions that included to monitor medications for side effects. A focus area of altered cardiovascular status related to myocardial infarction. A review of the Order Summary Report included but was not limited to; a physician's telephone order dated 04/26/23, for Atorvastatin (medication to treat hyperlipidemia) 80 mg (milligrams) give one tablet by mouth one time a day. A physician's telephone order dated 04/26/23, Senna-S (sennosides-docusate sodium) (a medication to treat constipation) give two tablets by mouth at bedtime for constipation hold for LBM (loose bowel movements). A review of the Medication Administration Record (MAR) dated 4/1/23 through 4/30/23, included but was not limited to; the physician ordered Atorvastatin plotted for 1800 (6:00 PM) with an x for the date 4/26/23. The physician ordered Senna plotted for 2100 (9:00 PM) with an x for the date 4/26/23. The MAR had documentation that five other physician ordered medications were administered on the evening shift to Resident #256. The MAR contained chart codes which have a numeric value to explain why a medication was not administered. The MAR did not include the numeric value from the chart code for the Atorvastatin or the Senna only an x. The MAR did not reveal any circle or staff initial per facility policy to indicate the medication was either withheld, refused, or given at a time other than the scheduled time. A review of the Progress Notes (PN) included but were not limited to; documentation starting on 4/26/23. The PNs failed to include any documentation that the physician was notified that Resident #256 had not received his/her Atorvastatin or Senna. The PNs also failed to document any monitoring or response related to Resident #256s omission of the two medications. On 01/31/24 at 8:40 AM, Surveyor #2 interviewed the Licensed Practical Nurse Unit Manager (LPN/UM). The LPN/UM stated that if there was no documentation, the medication was not administered. The LPN/UM further stated that any medications not administered would be noted why and the physician would also be notified. On 02/05/24 at 10:10 AM, during an interview with the surveyors, the Director of Nursing (DON) was asked what the expectation was for the staff who administered medications. The DON stated the medication should be documented and that if it was not administered, the physician should be notified. A review of the facility provided, Staff Nurse job description, undated, included but was not limited to; Purpose: provide direct nursing care to residents under the medical direction of the residents; attending physicians Charting and Documentation duties: charts relevant, concise, and descriptive manner that reflects the care provided to the resident and the resident's response to care. Planning and Delivery of care: assures resident care delivery in accordance with facility policies and procedures. Is responsible for administering and documenting medications according to the physician's order. A review of the facility provided, Administering Medications policy, updated 1/2023, included but was not limited to; medications are administered in a safe and timely manner as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit. 17. For residents otherwise unavailable to receive medication, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. 18. If a drug is withheld or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space for that drug and dose. A review of the facility provided, Documentation of Medication Administration policy, updated 1/2023, included but was not limited to; Interpretation and Implementation: 3. Documentation of medication includes as a minimum: f. reason(s) why a medication was withheld, not administered, or refused. A review of the facility provided, Charting and Documentation policy, updated 1/2023, included but was not limited to; Policy: all services provided progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition. 2. The following information is to be documented. b. medications administered. The facility failed to administer two medications to Resident #256. The facility failed to document the reasoning the medications were not administered or that staff contacted the physician regarding the medications for any physician orders if needed. NJAC 8:39-27.1, 29.3(5) 38079

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to revise a resident-centered on-going Care Plan (CP) for a resident who received oxygen therapy. This deficient practice was identified for 1 of 25 residents (Resident #47) reviewed for CP and was evidenced by the following: On 01/29/24 at 11:05 AM, the surveyor observed Resident #47 lying in bed. The resident was observed to be wearing a nasal cannula (nc) with oxygen tubing attached to an oxygen concentrator that was situated on the floor next to the bed. On 01/29/24 at 2:21 PM, the surveyor observed Resident #47 in his/her room lying in bed with a nc on, the oxygen tubing attached to an oxygen concentrator which was situated on the floor next to the bed. Resident #47 stated he/she was not aware of the amount of oxygen that he/she was receiving. A review of the Admission Record revealed that Resident #47 had diagnoses which included but were not limited to; chronic respiratory failure with hypoxia (lack of oxygen), paraplegia (a type of paralysis), anemia, and Chronic Obstructive Pulmonary Disease (COPD). A review of the quarterly Minimum Data Set (MDS) an assessment tool to facilitate resident care, dated 12/27/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 15/15 which indicated the resident was cognitively intact. The MDS further indicated the resident received oxygen therapy while a resident at the facility. A review of the Order Summary Report included an order dated 08/30/22, for oxygen 2 LPM (liters per minute) via nc (nasal cannula) PRN (as needed) for SOB (shortness of breath) which was discontinued. An order dated 12/28/23, to apply oxygen per nasal cannula/mask at 2 lpm to keep oxygen sats (saturations- % of oxygen in the blood) equal to or above 92% every shift for SOB and as needed. A review of the resident-centered on-going CP failed to document a focus area, any goals, any interventions, or time frames regarding Resident #47's oxygen therapy. On 02/02/24 at 9:28 AM, the Director of Nursing (DON) stated in that the information in a resident's CP included anything that pertained to resident such as if the resident was on hemodialysis or had hypertension (elevated blood pressure). The DON stated that the nursing department would update their specific areas of a resident care plan. She stated that if there was a new order or diagnosis, the care plan should be updated within three days. The DON further stated that it was important to keep the CP updated and current because it is the patient centered care. On 02/02/24 at 9:51 AM, the Licensed Practical Nurse (LPN) Unit Manager (LPN/UM) stated oxygen should be included on a resident's care plan. She stated she was responsible to update the resident care plans on her unit. The LPN/UM and the surveyor reviewed Resident #47's Care Plan. The LPN/UM acknowledged oxygen should be on the care plan, but it was not documented. The LPN/UM further stated that it was important to have anything related to care on the care plan, so all staff would know how to care for a resident. A review of the facility provided, Staff Nurse job description, undated, included but was not limited to; develops a nursing care plan, individualizing the care, revises as necessary. Routinely assesses the needs of the resident and adjust the care plans as needed. Reviews care plan daily to ensure that appropriate care is being rendered. A review of the facility provided, Nurse Manager job description, undated, included but was not limited to; oversees or initiates care plans based on resident needs identified in the Resident Assessment Protocol and update care plans. A review of the facility provided, Director of Nursing job description, undated, included but was not limited to; assist an d participate in the developing for each resident the preliminary and comprehensive assessment and plan of care that identifies medical problems and/or needs of the resident and the goals to be accomplished for each problem and/or need identified participate in assessing reviewing and revising care plans as required. A review of the facility provided, Care Plans, Comprehensive Person-Centered policy updated 01/2023, included but was not limited to; Statement: Includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Interpretation and Implementation: 2. Interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: a. includes measurable objectives and timeframes; b. describes services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. incorporates identified problem areas; h. incorporates risk factors associated with identified problems; k. reflects treatment goals, timetables, and objectives in measurable outcomes; identify the professional services responsible for each element of care. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the conditions change. NJAC 8:39-11.2

C#: NJ163142 Based on interviews, medical record review, and review of other pertinent facility documentation on [DATE] and [DATE], it was determined that the facility failed to ensure that a resident was provided a Carbohydrate Controlled Diet (CCD) with Chopped Texture. On [DATE], at approximately 8:00 a.m., Resident #2 was given a breakfast tray by the Certified Nursing Assistant (CNA) prepared by the kitchen. The tray included a whole doughnut in a plastic wrapper. The doughnut was not on the dietary slip and was not prepared chopped by the kitchen staff. The CNA assigned to Resident #2 set up the tray, cut the doughnut into quarters and left the Resident's room to help another Resident. At approximately 8:15 a.m., the housekeeping staff /Porter found Resident #2 on the floor face down and notified the Registered Nurse (RN). The RN found Resident #2 unresponsive and face down and rolled the Resident onto the back. The Licensed Practical Nurse (LPN) also responded to Resident #2's room, observed food in the Resident's mouth, and removed it. Resident #2 had a thready pulse; oxygen was applied, and 911 was called. The Paramedics and Police arrived at approximately 8:27 a.m. and pronounced Resident #2 deceased . The past noncompliance and Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed, and the deficient practice was corrected by [DATE] after the facility implemented a systemic plan before this current complaint survey began. The plan included the following: On [DATE]: All residents on Chopped Diets were identified, and their trays were immediately checked to ensure they were served the proper diet consistency. On [DATE]: Auditing of the Tray Line to ensure that the proper diet consistencies were served to the residents. On [DATE]: The Food Service Director (FSD) observed and audited the Lunch Tray Line to ensure proper diet consistencies were served to the residents. [One hundred percent] 100% compliance was noted. On ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] & ,d+[DATE]: The Administrator & Regional Food Service Director observed and audited the Dinner Tray Line to ensure the proper diet consistencies were served to the residents. One hundred percent compliance was noted. On [DATE]: The investigation results about what happened to Resident #2 were reviewed and analyzed by the QAPI [Quality Assurance and Performance Improvement] Committee. The members of the QAPI Committee reviewed the facility's Policy and Procedure related to Food and Nutrition Services and the facility's system for preparing and serving foods for residents on modified consistency diets. [Fifteen] 15 residents were identified as on a chopped Diet, including [two] chopped ground meat. On [DATE]: The FSD called the [NAME] who had prepared breakfast to discuss the incident earlier that day. When asked about his knowledge of preparing a doughnut for a resident on a chopped consistency diet, the [NAME] responded that the doughnut needs to be chopped. The FSD re-educated the [NAME] on preparing a modified chopped Diet. On [DATE], the facility had the [NAME] sign and dated the in-service. On [DATE]: The facility Educator initiated in-services for all Staff regarding modified diets. Emphasis was made on ensuring that residents with orders for Chopped Diets received the correct consistency on their meal trays. The CNA on the unit at the time of the incident was in service on [DATE], prior to the next scheduled shift. In-services on Modified Diets will continue until all Staff are educated and re-educated. Education on Modified Consistency Diets will be ongoing for new hires and annually for all Staff. On [DATE]: The facility began to evaluate the Cooks and Dietary Staff on their competency skills in preparing and serving modified consistency diets to ensure no reoccurrence of the same event. On [DATE]: A PIP (Performance Improvement Plan) was developed on Modified Consistency Diets and incorporated into the Facility Assessment and QAPI Program to promote the safety of residents on modified consistency diets. The Administrator or Designee conducted 3 [three] tray line observations weekly to ensure that residents on Chopped Diets were consistently served the proper food. The facility also failed to follow its policies titled Physician's Orders, Food and Nutrition Services, Complete Care Texture-Modified Diet Guidelines Chopped Diet, and the [NAME] Job Description, this deficient practice was identified for 1 of 19 residents (Resident #2) and was evidenced by the following: According to the Facility's Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents dated [DATE], with an event date of [DATE] and a time of event of 8:15 a.m., revealed the following: On [DATE], at approximately 8:15 a.m., Resident #2 was found on the floor by the Housekeeper face down in the doorway. The Resident had a thready pulse, oxygen was applied, and 911 was called. The Nurse noticed a food substance in the Resident's mouth and immediately removed all substances that were felt and seen. The Paramedics and Police arrived, and the Resident was pronounced deceased on the scene, and the body was released to the Medical Examiner. Further review of the FRE indicated the Resident's Diet was accurately followed. Review of Resident #2's Electronic Medical Record (EMR) was as follows: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Vascular Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety; Personal history of Transient Ischemic Attack (TIA) and Cerebral Infarction without Residual Deficits; and Type 2 Diabetes Mellitus with Hyperglycemia. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 had a Brief Interview of Mental Status (BIMS) score of ,d+[DATE], which indicated the Resident was moderately cognitively impaired. The MDS also showed Resident #2 needed supervision for transfers and was independent in eating with one person's physical assistance. A review of Resident #2's Care Plan (CP) initiated on [DATE] and revised on [DATE] revealed under Focus: Nutrition: Resident is overweight. The CP further revealed under Goal: Resident meal intake will be >50% (percent). [The] Resident will follow Diet as ordered. The Resident will not choke or aspirate. [The] Resident will lose ,d+[DATE] # wk. [pounds per week] The CP also included under Interventions: Monitor intake PRN. Monitor Weights and Labs as avail [available]. Notify MD [physician] of any significant weight changes PRN (as needed). Provide Diet as ordered. Provide with food/beverage preferences as available. A review of Resident #2's Medication Review Report with a date range of [DATE]-[DATE] revealed a Physician's Order: Dietary-Diet Order Summary: CCD [Carbohydrate Controlled Diet] diet Chopped texture, Thin Liquids consistency, ground meats with an order date of [DATE] and a start date of [DATE]. A review of Resident #2's Progress Notes (PNs) revealed the following: On [DATE] at 10:07 a.m., a Health Status Note written by the Registered Nurse (RN #2) revealed: Nurse [initials] on the unit stated that she was called to assess the Resident, and upon her arrival, he was found on the floor. Resident [#2] was face down in [his/her] doorway beside [his/her] walker. The Resident was unresponsive to verbal or tactile stimuli; however, he/she had a thready pulse. Oxygen was applied, and 911 was called The Residents chart was checked, and the Resident was noted to be DNR (Do Not Resuscitate) and DNI (Do Not Intubate). The Nurse stayed with the Resident until the paramedics/ police arrived. The medical examiner pronounced the Resident. On [DATE] at 10:07 a.m., a Health Status Note written by RN #2 revealed: IDT [Interdisciplinary Team] Note: Team met today to discuss the fall that occurred on [DATE]. The Resident was found on the floor, face down. The Nurse rolled the Resident over onto his back. She felt a thready pulse, and at that time, applied oxygen and called 911. A nurse noted food in his mouth, did a sweep of his mouth, and removed all substance that was felt and seen. During that time resident was noted without a pulse. Paramedics arrived and pronounced on the scene. A review of Resident #2's Speech Therapy SLP (Speech-Language Pathologist) Evaluation & Plan of Treatment revealed an Initial Assessment, Factors Supporting Medical Necessity, signed by the ST on [DATE] and by the Medical Doctor (MD) on [DATE].: Reason for Referral: Pt [patient] referred to ST [Speech Therapy] by the Director of Nursing (DON) due to [Resident #2] experiencing an episode of significant coughing when eating, resulting in him expelling food. Diet is regular with thin liquids. Per the staff report, the Pt [patient/Resident] is displaying impulsive behavior and no self-monitoring skills. Per RD [Registered Dietician], Pt's wife/caregiver reported that [the Resident] would take large amounts of food at home and would vomit. This [placed] the [Resident] at increased risk for aspiration. [Resident] also reported present[ing] with verbal agitation, decreased problem-solving, insight, and safety awareness. Skilled ST evaluation [is] indicated. A review of Resident #2's Speech Therapy SLP Evaluation & Plan of Treatment revealed an Assessment Summary dated [DATE] as follows: [ .] Pt [Resident #2] was unable to self-monitor size of each bite or reduce the rate of intake on [his/her] own. [Resident] had poor insight that eating fast and taking large amounts of food in one bite could increase [his/her] risk of choking/aspiration. For these reasons, it was recommended to continue the current Diet of chopped solids with ground meats. [Resident] has been consuming this diet texture w/o [without] exacerbation of dysphagia. [Resident] and Nursing were made aware. No further ST [Speech Therapy] is recommended. At the time of the survey, the facility could not provide documentation of Resident #2's meal ticket to include the Resident's meals for [DATE] with the food texture. During a telephone interview on [DATE] at 11:47 a.m., the CNA stated that she worked with Resident #2 often and was aware the Resident was on a chopped diet. According to the CNA, on [DATE] at approximately 8:00 a.m., she passed the breakfast food tray to Resident #2 and noticed that the doughnut was on the tray in a plastic wrapper and was not chopped. The CNA set up the tray, cut the donut in quarters, and then went to another room. At approximately 8:15 a.m., she heard a lot of noise and went towards Resident #2's room and saw the Resident in the doorway face down, and the RN was with the Resident. The CNA explained to the Surveyor that the RN checked Resident #2's pulse and said it was thready. The CNA helped the RN turn Resident #2 face up, and then LPN arrived, noticed food in the Resident's mouth, and did a finger sweep with a gloved hand. The LPN left to check the code status and to call 911. 911 arrived, took over the scene, and pronounced Resident #2 deceased . The CNA stated that Resident #2 was an independent eater who eats breakfast alone and lunch and dinner occasionally in the dining room. During an interview on [DATE] at 12:08 p.m., the Dietitian stated that she is responsible for writing the CP for Resident #2 for nutrition, and the Resident had a CP that mentioned resident will follow [the] diet as ordered and in interventions provide diet as ordered. During a second interview on [DATE] at 11:23 a.m., she stated that Speech Therapy downgraded Resident #2's Diet. The Diet was switched from a regular to a chopped texture and ground meat starting [DATE]. During an interview on [DATE] at 12:39 p.m., the Housekeeper/ [NAME] stated that he was about to sweep and mop when he spotted Resident #2 in the doorway between Resident #2's room and the hallway, face down and only the head visible as the body was inside the room. He stated that he did not touch the Resident and told the Nurse at the Nurse's station that a Resident was down on the floor. During an interview on [DATE] at 12:57 p.m., the RN stated that she was giving meds [medication] at the other end of the hallway when the [NAME] told her a Resident was on the floor, and she ran to Resident #2's room. The CNA helped her to turn over Resident #2, and the Resident's pulse was very thready. The RN stated she could not see food in the mouth because of the angle. LPN arrived, did a mouth sweep, retook the pulse, and could not get one. The LPN went to check the code status and call 911. At the same time, she stayed with the Resident until the Emergency Medical Services (EMS) arrived. During an interview on [DATE] at 1:30 p.m., the Food Service Director (FSD) stated that for a modified texture, the facility follows the corporate guideline for ground and chopped diets, and these guidelines are laminated and hung on the wall so the [NAME] and everyone in the kitchen can see them. The FSD stated that these are the only guidelines they follow and that the [NAME] is responsible for chopping the donuts, and if a resident on a chopped diet receives a whole donut, that means the [NAME] did not chop it as he should. During an interview on [DATE] at 2:40 p.m., the Administrator said the facility Corporate Managers met collaboratively and created a dietary guideline following numerous textbook manuals, including the American Dietary Association. The Administrator stated that the ticket on the tray shows that the food should be chopped, and it should be chopped in the kitchen. During a second interview later the same day at 4:35 p.m., the Administrator stated that an investigation was conducted regarding the incident on [DATE]. The breakdown was in the kitchen when the doughnut got through the tray line, and the food should have been cut in the kitchen. He further stated, The [NAME] should have cut the doughnut because the [NAME] is trained in how to cut it, not the CNA. During an interview on [DATE] at 10:55 a.m., the [NAME] stated that a resident on a chopped Diet should receive a doughnut cut into ,d+[DATE] inch pieces or cut in 4 because the donuts are mini donuts and are very small. The [NAME] stated that he does not recall if the doughnut was cut that day, and it may have slipped past us. He agreed that he was responsible for chopping up the food. During a second interview the same day at 2:00 p.m., the [NAME] stated that he was in-serviced right away, on a Zoom call and in person. During an interview on [DATE] at 11:54 a.m., the Speech Therapist stated Resident #2 was on a chopped diet, and the Resident's meats were ground. She further stated Resident #2 did not require supervision during meals because the diet texture modification eliminated the problem of him taking large amounts of food, the Resident's food should be chopped, and he/she was fine eating by himself. During a telephone interview on [DATE] at 2:48 p.m., the LPN stated the CNA called her to where Resident #2 was on the floor in the doorway. She arrived and saw something in the Resident's mouth and swept the mouth and could not specify the size of the food that was removed because it was mushy and like a muffin, very soft consistency, but I could not exactly identify it. She further stated that she received in-service on diet consistency and texture. When asked by the Surveyor what Staff should do when a regular meal is sent to a Resident on a therapeutic chopped diet, the LPN stated that Staff should return the meal to the kitchen if it's incorrect. During a second telephone interview on [DATE] at 11:48 a.m., the CNA stated that she was in-serviced by the LPN on the floor that same day. The CNA stated that trays should be checked by looking at the food to see if the texture of the food on the tray matches the ticket on the tray. She further stated that if it did not match, she would tell the Nurse, call the kitchen, and send the tray back to get the correct tray. When asked by the Surveyor what she should have done when she received the whole doughnut on Resident #2's tray, the CNA stated she should have returned the tray instead of cutting the doughnut herself. A review of the facility's policy titled Physician Orders, updated ,d+[DATE], included under Policy: Medication and treatment orders will be accepted only from authorized, credentialed physicians or from other authorized, credentialed practitioners in accordance with state regulations regarding prescriptive privileges. A review of the facility's policy dated 2001, titled Food and Nutrition Services, included under Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The document further reveals under Policy Interpretation and Implementation: 1. The multidisciplinary Staff, including nursing staff, the attending physician, and the Dietitian, will assess each Resident's nutritional needs, food likes, dislikes, and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake utilization. 2. A resident-centered Diet and nutrition plan will be based on this assessment. [ .] 6. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each Resident [ .]. A review of the updated facility's document titled Complete Care Texture-Modified Diet Guidelines Chopped Diet reveals under Food Group: Grains; Allowed: Chopped biscuits, muffins, pancakes, [ .] soft breads with crust removed, cut into quarters. A review of the updated facility's document titled [NAME] Job Description reveals under Purpose of Your Job Position: To prepare food in accordance with current applicable federal, state, and local standards, guidelines and regulation, with our established policies and procedures and as may be directed by the Food Services Director or Designee, to assure quality food service is provided at all times. To direct, evaluate, and monitor the Staff assigned to your department, including issuing disciplinary actions as necessary and performing probationary and annual evaluations of employee performance. Delegation of Authority: As Cook, you are delegated the authority, responsibility, and accountability necessary for carrying out your assigned duties. Job Functions: [ .] Inspect special diet trays to assure that the correct Diet is served to residents. NJAC: 8:,d+[DATE].4(a)(1,2) NJAC: 8:,d+[DATE].1(a)

COMPLAINT # NJ 5 Based on observations, interviews, review of Medical Records (MR), and review of other pertinent facility documentation on 4/5/2021 and 4/6/2021, it was determined that the facility staff failed to ensure that medications which could cause significant harm if ingested were stored/secured and inaccessible to cognitively impaired residents living on the dementia unit. On 4/5/2021 at 10:58 a.m., three medication bingo-cards containing a total of 56 pills, 14 [MEDICATION(S)] tablets, and 42 [MEDICATION(S)] capsules, were observed on the dementia unit nursing station desk unsecured and without staff within the line of sight of the medications. Three ambulatory residents were observed in the hallway within 20 feet of the nursing station, and four residents in wheelchairs were observed in front of the nursing station without any staff member observed within the line of sight of the medications. The Facility also failed to follow their Policies titled, Administering Medications, Accepting Delivery of Medications, and Storage of Medications, for 2 of 8 residents (Resident #7, and Resident #8) sampled. This placed all residents with cognitive impairment who were living on the dementia unit in an Immediate Jeopardy (IJ) situation. The IJ was identified on 4/5/2021 at 4:22 p.m., when the Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ situation and were provided the IJ template. The IJ ran from 4/5/2021 at 10:58 a.m., to 4/5/2021 at 5:23 p.m., when the Facility provided an acceptable Removal Plan which included in-servicing of the staff on Medication Storage, which removed the Immediacy. This deficient practice is evidenced by the following: 1. According to the Admission Record (AR), Resident #7 who lived on Unit #1 after being admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), an assessment tool dated 1/19/2021, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 6/15, which indicated the resident had severe cognitive impairment. The MDS also revealed that Resident #7 required extensive assistance for Activities of Daily Living (ADLs). According to the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. According to the Admission Record (AR), Resident #8 lived on Unit #1 after being admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 was discharged on [DATE]. Review of the Minimum Data Set (MDS), an assessment tool dated 3/13/2021, Resident #8 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS also revealed that Resident #8 required extensive assistance for Activities of Daily Living (ADLs). According to the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a Facility tour on the Dementia Unit on 4/5/2021 at 10:58 a.m., the surveyor observed a nurse passing medications from the medication cart in the hallway. Observed at the nursing station on the desk were 3 unsecured bingo-cards of medications. One bingo-card was labeled [MEDICATION(S)] 5 mg, 14 tablets were observed and the bingo-card was identified/labeled as Resident #7's medication. The 2 other bingo-cards were labeled [MEDICATION(S)] 400 mg, 42 capsules were observed and the bingo-cards were identified/labeled as Resident #8's medication. During the observation on 4/5/2021 at 10:58 a.m., of the unsecured medication at the nursing station desk four residents were observed sitting in wheelchairs in front of the nursing station and 3 residents were standing in the hallway within 20 feet from the nursing station and were independent ambulators. The nurse on the unit was not within eyesight of the medication bingo-cards and no other staff members were observed on the unit at the time the medication was observed as unsecured. During an interview on 4/5/2021 at 10:58 a.m., the Licensed Practical Nurse (LPN#1) reported that the medications were on the counter because she had received the medications from the night nurse that morning. The medications came from the pharmacy in a bag that morning at the start of her shift. They have been there all morning on the counter and were put there by the night nurse. LPN #1 reported that the night nurse told her the medications needed to go to Unit 1, however, the LPN was not sure why the night nurse did not take them to Unit #1 when she left. When questioned further LPN #1 stated that she did not deliver the medications to the other unit since she had been the only nurse on the unit that day. When asked if she called anyone to come pick up the medications she stated no and agreed it was an option. LPN #1 also agreed that medication left out is a safety issue, therefore, she should have locked the medications in the medication cart and not left them unsecured on the counter and within reach of residents, especially on the Dementia Unit. On 4/5/2021 at 11:03 a.m., prior to the surveyors leaving the Dementia Unit, LPN#1 was observed locking up the 3 bingo-cards on the medication cart. During an interview on 4/5/2021 at 2:44 p.m., the DON reported that the pharmacy delivers medications 2 times per day, at 4:00 p.m. and 11:00 p.m. The Supervisor accepts the medication delivery in the front vestibule and signs for them. It is the Supervisor's responsibility to check that each medication delivered is correct prior to signing for them. The Supervisor then gives the medication bag to the unit nurse who should in turn check the medications and the names of the residents on the medication to verify that the resident is on their unit. If the resident is not on that unit, the Supervisor is responsible to take that medication to the proper unit. The DON agreed that medications left out within residents' reach is a safety issue especially on the Dementia Unit and the error occurred because the Supervisor failed to verify the medications and verify that the resident's were on the Dementia Unit. In addition, the DON reported that the LPN should have secured the medications in the medication room for storage until she could take the medications to Unit #1. According to the DON, the Dementia Unit on 4/5/2021, had 21 cognitively impaired residents, 3 were able to ambulate independently and 5 were able to self-propel in their wheelchairs. Review of the Facility document titled Packing Slip Proof of Delivery, verified that the [MEDICATION(S)] 5 mg, 14 tablets for Resident #7 and [MEDICATION(S)] 400 mg, 42 capsules for Resident #8 were delivered to the facility on [DATE] at 5:21 a.m., and was signed for by the Nurse. During an interview on 4/6/2021 at 8:00 a.m., the Unit Manager (UM) reported that she was recently in-serviced on delivery and storage of medications and was found to be knowledgeable about the proper handling and securing of medications. During an interview on 4/6/2021 at 10:15 a.m., the Licensed Practical Nurse (LPN#2) reported that she was recently in-serviced on delivery and storage of medications and was found to be knowledgeable about the proper handling and securing of medications. On 4/6/2021, a tour was completed to verify that medications were secured properly and not within reach of residents on the Dementia Unit and the Facility was found to be compliant. According to the Facility policy titled Administering Medications, dated 10/2019, under Policy Statement; Medications shall be administered in a safe and timely manner, and as prescribed. Under Policy and Interpretation and Implementation; section 16, .No medications are kept on top of the cart. According to the Facility policy titled Accepting Delivery of Medications, dated 10/2020, under Policy Statement; section 1. All staff shall follow a consistent procedure in accepting medications. Under Policy Interpretation and Implementation: section 1. A nurse shall personally accept each medication delivery. According to the Facility policy titled Storage of Medications, updated 4/05/21, under Policy Heading: The facility stores all drugs and biological's in a safe, secure, and orderly manner. Under Policy Interpretation and Implementation: section 1. Drugs and illogical used in the facility are stored in locked compartments under proper temperature, light, and humidly controls. Section 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The IJ was identified on 4/5/2021 at 4:22 p.m., when the administrator (Admin) and the Director of Nursing (DON) were notified of the IJ situation and were provided the IJ template. The IJ ran from 4/5/2021 at 10:58 a.m., to 4/5/2021 at 5:23 p.m., when the Facility provided an acceptable Removal Plan which included in-servicing of the staff on Medication Storage, and disciplinary action to the nursing staff involved which, removed the Immediacy. The implementation of the Removal Plan was verified 4/06/21, on the second day of survey. This deficiency continues at a D level. N.J.A.C. 8:39-29.4(h)

C# Based on observation, interview and record review, it was determined that the facility failed to provide supervision in a manner that maximized resident safety and minimized the risk of accidents and injury. Resident #13 sustained a hip fracture which required hospitalization , surgical repair and pain management. The facility also failed to develop interventions for a resident (Resident #12), who had a history of [REDACTED]. This deficient practice was identified for Residents #12, and #13, 2 of 7 residents reviewed for falls with injuries, and was evidenced by the following: 1) During the initial tour of the West Unit on 4/1/14 at 11:10 a.m., the surveyor observed Resident #13 asleep in a low bed against the wall. A fall mat was on the floor next to the bed. A personal safety device used to detect resident's movement was attached to the bed. The Unit Manager (UM), who was providing the tour information, stated that Resident #13 had just been readmitted from the hospital. The UM stated that the resident had fallen off the toilet and sustained a hip fracture when a Certified Nursing Assistant (CNA) turned around to get a towel. When asked about safety devices used by the resident prior to this fall with fracture, the UM stated that the resident had an alarmed seat belt in the wheel chair and a tab and pressure sensitive alarm (personal safety alarm devices) in the wheel chair and bed. According to the medical record, Resident #13 had [DIAGNOSES REDACTED]. According to the January 2014 quarterly Resident Assessment Instrument (RAI), Resident #13 had impaired short term and long term memory and moderately impaired decision making skills. This RAI also indicated the resident was non-ambulatory and was dependent on staff for care and activities of daily living. The 1/16/14 Interdisciplinary Care Conference note revealed that the resident used an alarmed seat belt in the wheel chair which he/she was no longer able to remove. The alarmed seatbelt was removed every two hours for 15 minutes with close supervision for toileting, meals, etc. The ongoing interdisciplinary care plan (IDC) dated December 2012 identified that Resident #13 was at risk for falls related to being unaware of safety needs, deconditioning, psychoactive drug use, gait/balance problems, and incontinence. The ongoing interdisciplinary care plan also initiated December 2012 indicated that Resident#13 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease and required assistance with all decision making. A fall care plan that was initiated on 4/26/13 included the use of an alarmed seatbelt to prevent the resident from frequent unassisted rising from the wheel chair. A progress note dated 3/27/14 at 3:40 a.m. revealed that a CNA notified the nurse that she needed to go to Resident #13's room. The nurse documented that upon entering the room, she observed Resident #13 sitting on the bathroom floor. The nurse documented that the resident stated she slid off the toilet in an attempt to stand up while the CNA turned around to get a towel to clean her up. The nurse assessed the resident who complained of right hip pain. The physician was notified and ordered an x-ray of the resident's right hip. The nurse medicated the resident with Tylenol 650 milligrams (mg) at 1:05 a.m. for right hip pain. A progress note dated 3/27/14 at 6:29 a.m. indicated the x-ray was positive for right hip fracture and the physician ordered the resident be sent to the hospital emergency room . In a progress note dated 3/27/14 at 11:38 a.m., the nurse documented the resident was admitted to the hospital with [REDACTED]. In the next progress note entry, dated 3/31/14 at 5:18 p.m., the nurse documented that Resident #13, had surgery to repair the right hip fracture on 3/28/13 and was readmitted to the facility with a total of 46 staples on the right lateral leg. Subsequent nursing progress notes dated 4/2/14 through 4/8/14 included documentation of the resident's complaints of right hip pain for which administration of pain medication was required. According to documentation on the April 2014 Medication Administration Record (MAR), the nurse administered Percocet (a narcotic pain reliever) to the resident which provided pain relief. According to the Reportable Event Record/Report sent by the facility to the Department of Health on 3/31/14, Resident #13 was alert and confused and at times was able to make his/her needs known. On 3/27/14 at midnight, the resident's alarm sounded and the CNA, who was outside the resident's room, responded. The resident stated he/she needed to use the bathroom to have a bowel movement. After putting the resident on the toilet, the CNA stepped out to get a towel to clean the resident when the resident was done. The CNA heard the resident fall. The resident stated he/she tried to stand up and slid to the ground. The facility fall investigation included a statement dated 3/27/14 from the involved CNA who documented that after putting the resident on the toilet, she left the resident unattended on the toilet in the bathroom. The CNA documented that she went to get a towel from a cart in the hallway to clean the resident up. When reviewed, the resident's interdisciplinary care plan did not include supervision while toileting until after the resident fell and sustained a hip fracture. On 4/8/14 at 9:22 a.m., the surveyor observed Resident #13 in a low bed. The resident stated he/she hurt very badly on the right side of the body by the hip area. A CNA, who was in the room attending to the resident's roommate, stated she would notify the nurse that Resident #13 had pain. When interviewed by the surveyor on 4/9/14 at 10:45 a.m., CNA #1 stated that she had toileted the resident in the past, the last time approximately 2 weeks ago. CNA #1 stated that she always stayed in the bathroom with the Resident #13 because the resident was at risk for falls. When interviewed by the surveyor on 4/9/14 at 10:50 a.m., CNA #2 stated that she had toileted Resident #13 in the past. This CNA stated that she always stayed in the bathroom with this resident while the resident was on the toilet because sometimes the resident attempted to stand up. Both CNA #1 and CNA #2 stated that you can't leave any resident on the unit alone in the bathroom because they may try to stand up and fall. In addition, both CNAs stated that Resident #13 never asked for privacy when he/she was on the toilet. 2) During the initial tour on 4/1/14 at 10: 40 a.m., the UM stated that Resident #12 was in a wheel chair with a reverse seatbelt when out of bed. The UM stated that the resident tries to stand up and had fallen in the past. One fall resulted in a hematoma on the left side of the face. The surveyor observed Resident #12 on 4/2/14 at 10:40 a.m. in the unit dayroom. The resident was seated in a wheelchair with a reverse secured seatbelt. The resident self-propelled the wheel chair around the room. On 4/3/14 at 12:15 p.m., the surveyor observed the resident seated quietly in a wheelchair at a table in the unit dining room. According to documentation in the medical record, Resident #12 was admitted to the facility on [DATE] after a fall which resulted in a fracture hip. Resident #12 had a [DIAGNOSES REDACTED]. The February 2014 quarterly RAI indicated that Resident #12 was non-ambulatory, dependent on staff for care, and required the extensive assistance of 2 people for transfers. According to documentation in the resident's medical record, Resident #12 had several falls since admission. The surveyor reviewed the fall investigations that were provided by the facility. On 8/13/13 at 3:30 p.m., the resident was being assisted from a seated position on the toilet to the wheel chair by one person. During this one person transfer from a sitting to a standing position from the toilet, the resident slipped and fell on his/her buttocks. The fall investigation indicated that Resident #12 was to have two people for transfers. On 10/23/13 at 3:10 p.m., the resident was found sitting on the floor by the bed. The resident's wheel chair was in the bathroom and the alarmed seatbelt was unbuckled. According to the fall investigation, the chair alarm and seatbelt alarm was not functioning. The resident was able to unbuckle the alarmed seatbelt and disarm it. On 11/21/13 at 5 p.m., the resident was found on the bathroom floor. The fall follow-up note dated 11/25/13 indicated that the resident, who was known for repeated attempts to self-transfer, was given an alarmed seatbelt in the wheel chair which the resident opened and clasped to stifle the alarm. The resident also removed the tab alarm, a personal safety device, to alert staff to resident movement. A fall sustained on 11/21/13 was the third fall since Resident #12's admission. A request for a physical therapy/occupational therapy screen for a reverse seatbelt was requested. When interviewed by the surveyor on 4/9/14 at 8:50 a.m., the Director of Nursing (DON) stated that the reverse seatbelt was not considered because the resident was receiving physical therapy at the time. On 12/2/13 at 6:30 p.m., the staff documented they heard a faint sound of an alarm. Resident #12's door to the room and the bathroom door inside the room were both closed. The nurse found the resident between the toilet and the wheel chair trying to clasp the alarmed seatbelt. The resident sustained [REDACTED]. Ice was applied, the physician notified and the resident was sent to the emergency room . A CT scan of the head dated 12/2/14 indicated the resident had some facial swelling and a moderate hematoma. NJAC 8:39-27.1(a)

C# NJ Based on observation, interviews and a review of medical records and facility documentation, it was determined that the facility failed to implement an identified safety intervention, head gear, for 1 of 3 sampled residents, Resident #1, who had a known history of falls with injury. Resident #1 was being assisted with toileting when she fell backwards, hit her head and sustained a head injury requiring hospitalization and wound staples. This deficient practice is evidenced by the following: Medical records were reviewed and interviews conducted on day of survey, unless otherwise noted. 1. According to a facility Admission Record, dated 2/24/10, Resident #1 had multiple medical [DIAGNOSES REDACTED]. A review of the resident's Interdisciplinary Care Plan (IDCP), initiated on admission, identified a problem with falls risk. On 6/3/10, the care plan was updated to reflect a physician's orders [REDACTED]. The IDCP also documented the resident had four falls for the current year, not including the most recent fall. A quarterly Interdisciplinary Care Conference summary, dated 5/12/11, documented that the resident had four falls between 2/15/11 and 4/14/11, without injury. New interventions were noted and implemented. Subsequent review of a physician's orders [REDACTED]." An Interdisciplinary Progress Note (IPN), dated 2/16/11 at 10:00 a.m. which was written by the Unit Manager (UM), indicated the resident always had 1:1 assistance with toileting. The note also stated the resident wore hip pads at all times and a soft helmet. On 5/30/11, the Department of Health and Senior Services received a Reportable Event Record/Report from the facility indicating that Resident #1 was being assisted with toileting when she fell backwards and hit her head on the wall. The resident was assessed and immediately transported to the hospital. A requested facility Incident Report, dated 5/31/11, indicated the resident had sustained a 4 cm (centimeter) laceration to the back of the head. Subsequent review of an IPN, dated 5/29/11 at 2:30 p.m., indicated the resident was admitted to the hospital with [REDACTED]." An undated Incident Investigation statement form, which was written by the Certified Nursing Assistant (CNA) who toileted the resident, indicated that after using the toilet, Resident #1 washed her hands, picked up a paper towel off the floor, turned around and lost her balance. She fell backwards hitting her head on the wall. In a telephone interview with the surveyor at 10:45 a.m., the CNA who toileted the resident stated that she heard an alarm sounding and went into the resident's room. The resident was trying to get out of bed. The CNA said the resident told her she needed to go to the bathroom so she assisted her with toileting. The surveyor then asked the CNA about use of the resident's head gear. The CNA responded, "She only wears her helmet after she gets up and dressed. During the night, if she has to go to the bathroom, I just take her." On a tour of the secured unit at 10:00 a.m., accompanied by the UM, Resident #1 was observed sitting in her wheelchair in the dayroom. Her head gear was in place, as well as other identified safety interventions. She was unable to be interviewed. The UM stated that the resident frequently removes her head gear and needs to be reminded why it is in place. The surveyor asked the UM how the CNAs know what safety interventions are to be maintained. The UM said that each resident has an ADL (Activities of Daily Living) needs sheet posted inside the resident's closet door. The surveyor requested to see Resident #1's ADL needs sheet. A review of Resident #1's Resident Care Profile at a Glance form (ADL needs sheet), which was posted in the resident's room, lacked any documentation of the care plan intervention and physician's orders [REDACTED]. According to the hospital History and Physical, dated 5/29/11, Resident #1 sustained a "New post-traumatic subdural hematoma" and was admitted for observation and monitoring. An IPN, dated 5/31/11 at 2:40 p.m., indicated the resident returned to the facility with "5 staples present in lower back of head." NJAC 8:39-27.1(a)