Every finding on record at Complete Care at Madison, LLC

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure medications (meds) were administered in the allotted timeframe for 1 of 1 resident (Resident #122) reviewed for medication administration times.This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.1.On 2/25/26 at 11:01 AM, during an initial tour, the surveyor observed Resident #122 awake, alert and walking in their room. Resident #122 stated that the nurses took long time to administer their morning meds. Resident #122 stated I have diabetes and I am on insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood). The surveyor reviewed the hybrid Medical Record (MR; paper and electronic MR) for Resident #122.A review of Resident #122's admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; alcoholic cirrhosis (a condition where the liver is severely damaged) of liver with ascites (abnormal buildup of fluid within the abdomen usually causing swelling, abdominal pain and sometimes breathing difficulties), type 2 diabetes mellitus (DM2) with diabetic polyneuropathy (a type of nerve damage caused by long-term high blood sugar), major depressive disorder (a common but serious mental health condition characterized by a persistent, intense and long lasting low mood, sadness, or loss of interest in daily activities), and hepatic encephalopathy (loss of brain function occurs when the liver is unable to remove toxins from the blood). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 1/2/26, reflected that the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated that Resident #122 had intact cognition. Further review of the MDS indicated that the resident received insulin, antidepressant (medications used to treat depression) and diuretics (also known as water pills; medicines that help you move extra fluid and salt out of your body). A review of the individualized comprehensive care plan created on 12/26/25 included a focus care area that the resident had diabetes mellitus. Intervention included but were not limited to: diabetes medication as ordered by doctor. Other focus area reflected: Resident used antidepressant medication related to (r/t) depression; Resident was on diuretic therapy related to edema (swelling); Resident was at risk for ascites r/t cirrhosis. A review of Resident #122's Order Summary Sheet (OSR) included the following physician orders (PO): A PO dated 12/26/25 for Duloxetine HCL Capsule Delayed Release Particles 30 milligram (mg) - give 1 capsule by mouth at bedtime for depression.A PO dated 12/26/25 for Famotidine Oral Tablet 20 mg - give 1 tablet by mouth at bedtime for gerd (a chronic condition where stomach acid frequently flows back into the esophagus, the tube connecting the mouth and stomach).A PO dated 12/26/25 for Furosemide oral tablet 40 mg- give 1 tablet by mouth two times a day for ascites/edema.A PO dated 12/26/25 for Gabapentin capsule 300 mg- give 1 capsule by mouth every 8 hours for nerve pain.A PO dated 1/8/26, for Insulin Glargine-yfgn (type of long acting insulin to control blood sugar) subcutaneous solution pen-injector 100 units/milliliter (ml)- Inject 42 units subcutaneously (sq; injecting directly into the fatty tissue layer just underneath the skin) at bedtime for DM2. A PO dated 12/27/26 for Insulin Lispro (type of rapid acting insulin to control blood sugar) 100 units/ml solution. Inject as per sliding scale: if . , sq before meals and at bedtime for DM. A PO dated 12/26/25 for Lactulose oral solution 10 gram (gm)/15 ml- give 20 ml by mouth two times a day for Liver disease.A PO dated 12/26/25 for Sofosbuvir-Velpatasvir oral tablet 400-100 mg- give one tablet by mouth one time a day for Hepatitis (Hep; a viral infection that causes liver swelling) C. A PO dated 1/29/26 for Spironolactone oral tablet 100 mg- give two tablets (tab) by mouth one time a day for ascites/edema. Give two tabs = 200 mg.A review of the February 2026 Progress Notes (PNs) revealed no documentation regarding Resident #122's meds not being administered as scheduled per POs.A review of the Medication Administration Audit Report, dated 2/1/26 through 2/24/26, revealed the following:On 2/1/26: 1.Spironolactone 100 mg two tablets, scheduled for 9:00 AM was administered at 10:56 AM.2.Furosemide 40 mg tablet, scheduled for 9:00 AM was administered at 10:55 AM.3.Lactulose 20 ml, scheduled for 9:00 AM was administered at 10:55 AM.4.Sofosbuvir-Velpatasvir tablet, scheduled for 9:00 AM was administered at 11:04 AM.5.Insulin Lispro 6 units before meals, scheduled for 11:30 AM was administered at 12:54 PM.On 2/4/26:1.Insulin Lispro 2 units before meals, scheduled for 7:30 AM was administered at 8:58 AM.2.Insulin Lispro 8 units before meals, scheduled for 11:30 AM was administered at 12:38 PM.On 2/5/26:1. Insulin Lispro 4 units before meals, scheduled for 11:30 AM was administered at 13:27 PM.2. Insulin Lispro 4 units before meals, scheduled for 4:30 PM was administered at 7:16 PM.3.Furosemide 40 mg tablet, scheduled for 5:00 PM was administered at 7:15 PM. 4.Insulin Gilargine-yfgn 42 units scheduled at bedtime for 9:00 PM was administered at 6:51 PM.5.Insulin Lispro 6 units before meals, scheduled for 9:30 PM was administered at 10:56 PM.On 2/6/26:1.Spironolactone 100 mg two tablets, scheduled for 9:00 AM was administered at 11:33 AM.On 2/7/26:1.Spironolactone 100 mg two tablets, scheduled for 9:00 AM was administered at 10:14 AM.2.Furosemide 40 mg tablet, scheduled for 9:00 AM was administered at 10:14 AM.3.Lactulose 20 ml, scheduled for 9:00 AM was administered at 10:14 AM.4.Sofosbuvir-Velpatasvir tablet, scheduled for 9:00 AM was administered at 10:14 AM.5. Furosemide 40 mg tablet, scheduled for 5:00 PM was administered at 9:43 PM.On 2/8/26: 1.Spironolactone 100 mg two tablets, scheduled for 9:00 AM was administered at 10:35 AM.2.Furosemide 40 mg tablet, scheduled for 9:00 AM was administered at 10:35 AM.3.Lactulose 20 ml, scheduled for 9:00 AM was administered at 10:35 AM.4.Sofosbuvir-Velpatasvir tablet, scheduled for 9:00 AM was administered at 10:35 AM.5. Gabapentin 300 mg capsule, scheduled for 2:00 PM was administered at 3:40 PM. 6. Furosemide 40 mg tablet, scheduled for 5:00 PM was administered at 7:08 PM.7.Famotidine 20 mg tablet, scheduled for 9:00 PM was administered at 10:15 PM.8.Duloxetine 30 mg capsule, scheduled for 9:00 PM was administered at 10:15 PM. 9.Lactulose 20 ml, scheduled for 9:00 PM was administered at 10:15 PM.10.Insulin Gilargine-yfgn 42 units scheduled at bedtime for 9:00 PM was administered at 10:15 PM.On 2/9/26:1.Insulin Lispro 4 units before meals, scheduled for 7:30 AM was administered at 9:24 AM.On 2/13/26:1.Spironolactone 100 mg two tablets, scheduled for 9:00 AM was administered at 11:13 AM.2.Furosemide 40 mg tablet, scheduled for 9:00 AM was administered at 11:13 AM.3.Lactulose 20 ml, scheduled for 9:00 AM was administered at 11:13 AM.4.Sofosbuvir-Velpatasvir tablet, scheduled for 9:00 AM was administered at 11:13 AM.5.Furosemide 40 mg tablet, scheduled for 5:00 PM was administered at 6:34 PM.On 2/14/26:1.Spironolactone 100 mg two tablets, scheduled for 9:00 AM was administered at 2:52 PM.2.Furosemide 40 mg tablet, scheduled for 9:00 AM was administered at 2:52 PM.3.Lactulose 20 ml, scheduled for 9:00 AM was administered at 2:52 PM.4.Sofosbuvir-Velpatasvir tablet, scheduled for 9:00 AM was administered at 2:52 PM.5. Insulin Lispro 4 units before meals, scheduled for 11:30 AM was administered at 12:52 PM.On 2/15/26:1.Spironolactone 100 mg two tablets, scheduled for 9:00 AM was administered at 10:32 AM.2.Furosemide 40 mg tablet, scheduled for 9:00 AM was administered at 10:32 AM.3.Sofosbuvir-Velpatasvir tablet, scheduled for 9:00 AM was administered at 10:32 AM.4. Gabapentin 300 mg capsule, scheduled for 2:00 PM was administered at 3:15 PM. 5. Insulin Lispro 8 units before meals, scheduled for 4:30 PM was administered at 5:50 PM. On 2/16/26:1. Furosemide 40 mg tablet, scheduled for 5:00 PM was administered at 6:22 PM.2.Famotidine 20 mg tablet, scheduled for 9:00 PM was administered at 10:24 PM.3.Duloxetine 30 mg capsule, scheduled for 9:00 PM was administered at 10:24 PM. 4.Lactulose 20 ml, scheduled for 9:00 PM was administered at 10:24 PM.On 2/17/26:1.Famotidine 20 mg tablet, scheduled for 9:00 PM was administered at 10:52 PM.2.Duloxetine 30 mg capsule, scheduled for 9:00 PM was administered at 10:52 PM. 3.Lactulose 20 ml, scheduled for 9:00 PM was administered at 10:56 PM.4.Insulin Gilargine-yfgn 42 units scheduled at bedtime for 9:00 PM was administered at 10:53 PM.5.Insulin Lispro 6 units before meals, scheduled for 9:30 PM was administered at 10:54 PM.On 2/18/26:1.Insulin Lispro 6 units before meals, scheduled for 7:30 AM was administered at 8:45 AM.2.Insulin Lispro 4 units before meals, scheduled for 11:30 AM was administered at 12:47 PM.3.Insulin Lispro 10 units before meals, scheduled for 4:30 PM was administered at 5:49 PM.On 2/19/26:1.Insulin Lispro 8 units before meals, scheduled for 7:30 AM was administered at 8:43 AM.2.Insulin Lispro 8 units before meals, scheduled for 11:30 AM was administered at 12:40 PM.On 2/20/26: 1.Insulin Lispro 6 units before meals, scheduled for 11:30 AM was administered at 1:40 PM.2.Insulin Lispro 4 units before meals, scheduled for 4:30 PM was administered at 6:12 PM.3.Furosemide 40 mg tablet, scheduled for 5:00 PM was administered at 6:13 PM.4.Famotidine 20 mg tablet, scheduled for 9:00 PM was administered at 10:26 PM.5.Duloxetine 30 mg capsule, scheduled for 9:00 PM was administered at 10:26 PM. 6.Lactulose 20 ml, scheduled for 2100 (9:00 PM) was administered at 2226 (10:26 PM).7.Insulin Gilargine-yfgn 42 units scheduled at bedtime for 9:00 PM was administered at 10:26 PM.On 2/21/26: 1.Gabapentin 300 mg capsule, scheduled for 2:00 PM was administered at 3:12 PM.On 2/22/26:1.Furosemide 40 mg tablet, scheduled for 5:00 PM was administered at 6:33 PM.On 2/23/26: 1.Spironolactone 100 mg two tablets, scheduled for 9:00 AM was administered at 11:04 AM.2.Furosemide 40 mg tablet, scheduled for 9:00 AM was administered at 11:04 AM.3.Lactulose 20 ml, scheduled for 9:00 AM was administered at 11:04 AM. 4.Sofosbuvir-Velpatasvir tablet, scheduled for 9:00 AM was administered at 11:04 AM.5. Furosemide 40 mg tablet, scheduled for 5:00 PM was administered at 8:43 PM.On 2/24/26:1.Spironolactone 100 mg two tablets, scheduled for 9:00 AM was administered at 11:02 AM.2.Furosemide 40 mg tablet, scheduled for 9:00 AM was administered at 11:02 AM.3.Lactulose 20 ml, scheduled for 9:00 AM was administered at 11:02 AM. 4.Sofosbuvir-Velpatasvir tablet, scheduled for 9:00 AM was administered at 11:02 AM.5.Insulin Lispro 2 units before meals, scheduled for 4:30 PM was administered at 5:44 PM.7.Famotidine 20 mg tablet, scheduled for 9:00 PM was administered at 11:00 PM.8.Duloxetine 30 mg capsule, scheduled for 9:00 PM was administered at 11:00 PM.9.Lactulose 20 ml, scheduled for 9:00 PM was administered at 11:07 PM.10.Insulin Gilargine-yfgn 42 units scheduled at bedtime for 9:00 PM was administered at 11:00 PM.11.Insulin Lispro 4 units before meals, scheduled for 9:30 PM was administered at 11:00 PM.On 2/27/26 at 12:48 PM, during the interview with the surveyor, the Licensed Practical Nurse (LPN) stated that medications were to be administered one hour before or one hour after the scheduled administration time. The LPN explained if a medication like insulin was due at 7:30 AM, it could be given between 6:30 AM - 8:30 AM and further stated it should not be administered an hour and a half later, it would be a med error. The LPN stated insulin would be administered before meals as per the physician order. The LPN stated she was familiar with Resident #122. The LPN could not explain why Resident #122's medications were administered late.On 3/2/26 at 12:00 PM, during an interview with the surveyor, the Director of Nursing (DON) stated the meds should be administered one hour before or one hour after the due time. The DON stated there were five rights for med administration: Right Patient (resident), Right Drug, Right Dose, Right Route and Right Time. The DON further stated if the nurses were missing any meds or if the meds were delayed, the nurses should inform the physician. The surveyor made the DON aware of the above-mentioned concerns for Resident #122 and the DON acknowledged late med administration was not acceptable. The DON further stated the nurses should report it to the physician and document that in Progress Notes (PN) in EMR. The DON stated if the insulin was due at 9:00 PM, the earliest it could be given was at 8:00 PM and it was unacceptable to administer at 6:51 PM. The surveyor reviewed the Med Audit report with the DON for late med administration and the DON stated he was not aware of it and had to investigate that. On 3/2/26 at 1:43 PM, the survey team met with the DON, Licensed Nursing Home Administrator (LNHA), Regional Nurse Consultant (RNC), Regional Director of Operations (RDO). The surveyor made the facility administration aware of the above-mentioned concerns for Resident #122. A review of the facility's Medication Administration policy dated revised on 10/25 revealed Policy: Medications are administered .as ordered by the physician and in accordance with professional standards of practice. Under section Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed: e. Right timeA review of the facility's Administering Medications policy date updated 10/22 revealed Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Under section Policy Interpretation and Implementation: 2. Mediations must be administered in accordance with the orders, including any required time frame. 3. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 5. The individual administering the medication must check the label against the physician's order to verify the right resident,.right time before giving the mediation. 11.If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication will document in medication administration record.A review of the facility provided, Licensed Practical Nurse Job Description included but was not limited to; Major Duties and Responsibilities: Prepares and administers medications as per physicians' orders . Additional Assigned Taks: Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with ., and state/federal regulations and guidelines. N.J.A.C. 8: 39-27.1

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) provide a resident's activities of daily living (ADL) care in a dignified manner (Resident #135) and b.) ensure residents were transported from one area of the unit to another in a dignified manner (Resident #100 and #96). This deficient practice was identified on 1 of 3 units and was evidenced by the following:1.On 2/25/2026 at 10:44 AM, the surveyor observed the door open to Resident #135s room. From the hallway, the surveyor observed the resident in bed, lying on their left side, with the blankets pulled down. The resident was not covered, and the curtains were not drawn. The resident was wearing an adult brief. The resident's bed was in a high position. At that time, the resident's roommate left the room. A male aide was observed in the hallway, who then entered the room and shut the door. On 2/25/2026 at 10:55 AM, the surveyor remained in the hallway and the roommate returned to room. The roommate opened the door, and the surveyor observed Resident #135 was still receiving care. The curtain was not drawn. The roommate shut the door behind them. The surveyor reviewed the electronic medical record (EMR) for Resident #135. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; spastic diplegic cerebral palsy (a neuromuscular disorder characterized by high muscle tone primarily affecting the legs, leading to stiffness, a scissoring gait, and potential walking difficulties), schizoaffective disorder, unspecified (a chronic mental health condition combining hallucinations, delusions, disorganized speech with major mood disorder episodes (mania or depression)) and legal blindness, as defined in USA. A review of the Minimum Data Set (MDS) an assessment tool dated 1/17/2026, revealed the resident's Brief Interview for Mental Status (BIMS) was unable to be accessed, indicating the resident was severely cognitively impaired. Further reviewed revealed the resident was dependent on staff for care. A review of the individual comprehensive care plan (ICCP) revealed a focus of an ADL self-care performance deficit r/t (related to) Disease Process, Date Initiated: 08/13/2024. On 2/26/2026 at 11:13 AM, the surveyor interviewed the hospice aid (HA) #1, who confirmed he was the one who provided ADL care to Resident #135 the day before. He stated while providing care for residents the curtains should be pulled for privacy. He stated the resident's bed should always be in the lowest position before he left the room. The surveyor reviewed the above observation with HA #1. HA #1 stated he forgot an adult brief, so he ran out of the room to get one. He acknowledged he should have drawn the curtain, covered the resident, and put the bed down to low position before he left the room. 2. On 2/25/2026 at 11:27 AM, during the initial tour of the A wing unit, the surveyor observed resident #100 sitting in the main activity area in a recliner chair. On 2/26/2026 at 9:22 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 transport Resident#100 in a recliner chair facing backwards from the main activity area to their room. Resident #100 waived to the surveyor as they were transported down the hallway. On 2/26/2026 at 9:27 AM, the surveyor observed LPN #1 return Resident #100 in the recliner chair to the activity area by transporting the resident rear facing. On 2/26/2026 at 9:28 AM, the surveyor interviewed LPN #1 who stated residents should be transported facing forward for safety. He stated staff should be able to see residents during transport because residents may try to get out of the chair. The surveyor reviewed the above observation with LPN #1, who acknowledged he should have turned the resident around. The surveyor reviewed the EMR for Resident # 100. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, unspecified severity, with agitation (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions) and anxiety disorder, unspecified, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life). A review of the MDS dated [DATE] revealed the resident had a BIMS of 00 out of 15, indicating the resident was severely cognitively impaired. Further review revealed the resident required supervision or touching assistance with transfers. A review of the ICCP revealed a focus of has an ADL self-care performance deficit r/t Disease Process Date Initiated: 09/22/2025 and has limited physical mobility. [identifier redacted] utilizes a [name redacted] (reclining chair) when OOB, Date Initiated: 07/25/2023 3. On 2/25/2026 at 11:27 AM, during the initial tour of A wing unit, the surveyor observed resident #96 sitting in the main activity area in a recliner chair.On 2/26/2026 at 9:35 AM, the surveyor observed HA #1 transport Resident #96 in reclining chair, facing backwards, from their room to the main activity area. On 2/26/2026 at 11:13 AM, the surveyor interviewed HA #1, who stated residents should be transported forward facing for safety. The surveyor reviewed the above observation for Resident # 96 with HA #1, who acknowledge he should have transported the resident forward facing.The surveyor reviewed the EMR for Resident #96. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance and anxiety disorder, unspecified. A review of the MDS dated [DATE], revealed the resident had a BIMS) of 00 out of 15, indicating the resident was severely cognitively impaired. Further review revealed the resident was dependent for transfers. A review of the ICCP revealed a focus of an ADL self-care performance deficit r/t Disease Process, Date Initiated: 10/01/2025 with an intervention of transfer: The resident requires maximum assistance by 1 staff to move between surfaces. Date Initiated: 10/01/2025. On 2/26/2026 at 11:20 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) #1, who stated ADL care should be provided with privacy by pulling the curtain and closing the door, especially if there was a roommate. The surveyor made her aware of the above observation for Resident #135. LPN/UM #1 stated that should not have happened, resident's privacy should always be maintained. During the same interview, LPN/UM #1 stated residents should always be transported forward facing in their chair for safety and so the residents would not get disoriented. The surveyor made LPN/UM #1 aware of the above observations for Resident #100 and #96. On 2/26/2026 at 11:38 AM, the surveyor interviewed the Director of Nursing (DON), who stated while performing care the most important thing was purely privacy. He stated the curtain should be pulled completely closed and the resident should be covered for dignity. The DON stated a resident's bed should never be left in a high position for safety. The surveyor made the DON aware of the above observations for Resident #135. During the same interview, the DON stated residents should always be transported forward facing in their chair so you (the staff) could make sure they (the resident) did not fall. The surveyor made the DON aware of the above observations for Resident #100 and #96. On 3/2/2026 at 1:43 PM, in the presence of the survey team, the DON, the Licensed Nursing Home Administrator, the Regional Clinical Director and the Regional Director of Operations were made aware of the above concerns for Residents #135, #100, and #96. A review of the facility policy Promoting/Maintaining Resident Dignity date implemented 9/1/23 revealed Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment .Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. NJAC 8:39-4.1(a)12,16

Based on interviews, record reviews, and review of pertinent facility documentation, it was determined that the facility failed to accurately code a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 2 of 30 residents (Resident #90 and #132) reviewed for accurately coding the MDS according to the Resident Assessment Instrument (RAI - used to assess and care plan residents). The deficient practice was evidenced by the following: 1.On 2/25/26 at 10:37 AM, during initial tour, Resident #90 was observed in their room in their bed. Resident #90 then stated that they were a smoker, and they could smoke up to four times a day. They further stated that the facility holds onto their cigarettes until it was time to smoke. On 2/25/26 at 11:16 AM, the surveyor reviewed a list of smokers provided by the facility. Resident #90 was identified as a smoker. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; nicotine dependence (compulsive addiction to tobacco products). A review of the most recent comprehensive MDS dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact cognition. A further review in Section J, Health Conditions, the question for tobacco use was marked as no, which meant Resident #90 was assessed as a non-smoker. A review of CJCARE Smoking Assessment & SPN's dated 7/22/25, 10/3/25, 10/23/25, and 1/23/26, included in the section titled history, that the resident was currently a smoker. A review of the resident's smoking contract revealed the resident signed a smoking contract in September 2023. On 2/26/26 at 1:18 PM, the surveyor interviewed the Recreational Aide who stated that the resident would usually come out to smoke in the evenings as they liked to sleep in during the day. On 2/27/26 at 11:28 AM, the surveyor interviewed the MDS Coordinator (MDSC) who stated that when completing an annual MDS resident assessment she received information on the resident from progress notes and assessments completed by the nursing and activities department. She further stated that she reviewed all the MDS resident assessments for accuracy prior to submission. The MDSC verified that section J1300 for resident #90 was checked off as no for tobacco use. She confirmed that the resident did use tobacco and stated, I apologize for the mistake. On 2/27/26 at 12:07 PM, the surveyor interviewed the MDSC who stated that she reviewed the MDS resident assessment documentation and that it was a data entry error on her part. She further apologized and stated that she will initiate an MDS assessment modification to indicate that the resident did use tobacco. On 3/3/26 at 9:46 AM, the Regional Nurse Consultant, in the presence of the Licensed Nursing Home Administer (LNHA), DON, Regional Director of Operations, [NAME] President of Clinical Operations and the survey team acknowledged that MDSC should be using resident assessments such as the smoking assessments when completing annual MDS resident assessments to accurately reflect the resident. 2.On 2/25/2026 at 10:13 AM, during initial tour, Resident #132 was observed alert in their room lying in their bed. The resident stated that they had been at the facility for approximately three weeks. A review of Resident #132 admission Record reflected that the resident was admitted with diagnoses that included but not limited to; Schizophrenia and Bipolar disorder. A review of Resident #132's admission MDS dated [DATE] in section B Comatose, was coded as one (1), indicating that Resident #132 was in a persistent vegetative state or had no discernible consciousness. A review of Resident 132's progress notes reflected on 1/14/2026 a Brief Interview for Mental Status (BIMS) assessment, a brief verbal test used to check a resident's mental status or cognitive function, was completed. The progress note reflected that the BIMS assessment revealed, Resident #132 had a BIMS of 15 out of 15, indicating that Resident #132 was cognitively intact. Further review of progress notes further revealed a progress note dated 1/13/26 that the resident was received at the facility Alert and verbal. On 2/27/2026 at 11:28 AM, the surveyor interviewed the MDSC, who indicated the submission of the MDS assessments were completed by nursing staff, social work as well as the MDSC and ultimately the information was entered into the MDS by the MDSC. When questioned why Resident #132 was coded as comatose the MDSC indicated they would need to further investigate. On 2/27/2026 at 12:07 PM, the MDSC stated she had reviewed documentation for Resident #132 and stated that it was, a data entry error on my part. The MDSC further stated that they have already initiated a modification to correct the error. A review of the facility's MDS 3.0 Completion policy, date revised 10/30/2025, included.residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan.according to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. NJAC 8:39-33.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary services to maintain adequate grooming for a resident who was dependent on the staff for Activities of Daily Living (ADL). This deficient practice was observed for 1 of 1 resident (Resident #81) reviewed for ADL care. The deficient practice was evidenced by the following:On 2/25/26 at 10:28 AM, during an initial tour, the surveyor observed Resident #81 sitting in their wheelchair (w/c). The resident stated I am in bad shape while showing the surveyor both of their hands with long, jagged fingernails with sharp edges and then pointed towards their chin that had grey colored, curled up facial hair. Resident #81 stated I have asked them (the staff) to shave many times. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #81:A review of the admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included, but were not limited to; Anemia (a shortage of healthy red blood cells or hemoglobin, which prevents the body from getting enough oxygen), malaise (a feeling of lack of energy or general weakness) and muscle weakness.A review of the quarterly Minimum Data Set (MDS) an assessment tool dated 12/9/25, revealed the Resident #81 had a Brief Interview for Mental Status (BIMS) of 6 out of 15, indicating the resident's cognition was severely impaired. Further review revealed Resident #81 was dependent on staff for all their ADLs including personal hygiene.A review of the individualized comprehensive care plan (ICC) created on 8/14/24 included a focus area that the resident had an ADL self-care performance deficit related to impaired balance. Interventions initiated 10/9/25 included but were not limited to .Bathing/showering: Check nail length and trim and clean on bath day and as necessary. On 2/26/26 at 1:24 PM, the surveyor observed Resident #81 in their w/c. The surveyor observed Resident #81's both hands with long, jagged fingernails with sharp edges and facial hair. Resident #81 stated, I have told one of the girls (Certified Nurse Aid/CNA) regarding my nails and facial hair and she (the CNA) said she would trim them sometime today.On 2/27/26 at 11:54 AM, the surveyor observed resident sitting in their w/c. The surveyor observed Resident #81's long jagged fingernails on both hands and facial hair. Resident #81 stated, I have tried to do my left-hand nails myself, but they (the staff) do not want me to do it.On 2/27/26 at 12:15 PM, during an interview with the surveyor, the CNA stated during bed bath and/or shower, she would provide the resident hair care, nail care, foot care like applying lotion to their feet after washing them and shave them if it was needed. The CNA stated if the resident asked her to shave their facial hair, then she would do it for appearance. The CNA then stated, I do not think a [identifier redacted] wants to keep a beard. The CNA further stated the nail care was important for hygiene, residents could scratch themselves and they dig into places and touch everywhere. The surveyor accompanied by the CNA went to Resident #81's room and after looking at the resident's fingernails on both hands, the CNA stated, resident's nails were fine and the resident stated their nails were too long and wanted their fingernails to be trimmed and their facial hair to be shaved. On 2/27/26 at 12:28 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who was responsible for providing education to all the staff. The ADON stated the CNAs should be checking resident's nails daily during care. The ADON further stated the nail care was important for infection control and residents could hurt themselves by scratching. The ADON stated facial hair should be shaved for dignity and further stated, I do not want a [identifier redacted] to be sitting there with their facial hair. In the presence of the surveyor, the ADON reviewed the Electronic Medical Records (EMR) for Resident #81 and confirmed there was no documentation for nail care. In the presence of the surveyor, the ADON observed and acknowledged that Resident #81's fingernails and facial hair needed to be trimmed.On 3/2/26 at 11:59 AM, the surveyor interviewed the DON who stated hygiene was very important for infection control and presentation. The DON stated the expectation from the staff was to provide nail care and shaving assistance at the resident's request and as needed. The surveyor made the DON aware of the above-mentioned concerns for Resident #81. On 3/2/26 at 1:43 PM, the survey team met with the DON, Licensed Nursing Home Administrator (LNHA), Regional Nurse Consultant (RNC), Regional Director of Operations (RDO). The surveyor made the facility administration aware of the above-mentioned concerns for Resident #81. A review of the facility's Activities of Daily Living (ADLs) policy dated implemented on 9/24 revealed: Care and services will be provided for the following activities of daily living: 1. Bathing, dressing grooming and oral care; Under section Policy Explanation and Compliance Guidelines:2. A resident who is unable to carry out activities of daily living will received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.A review of the facility's Grooming a Resident's facial hair undated policy revealed under Policy: It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standard of practice.A review of the facility's Nail Care policy dated implemented on 9/24, provided on 3/2/26, revealed under Policy: The purpose .to provide guidelines for the provision of care to a resident's nails for good grooming and health. Under section Policy Explanation and Compliance Guidelines: 2. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 3. Routine nail care, to include trimming and filling, will be provided on a regular basis and as needed. 4. Procedure: h. Document completion of task, any complications, or if resident refuses. A review of the facility's Nail Care policy dated implemented on 9/24, provided on 3/3/26, revealed under Policy: The purpose .to provide guidelines for the provision of care to a resident's nails for good grooming and health. Under section Policy Explanation and Compliance Guidelines: 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filling, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. 6. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. A review of the facility provided, Licensed Practical Nurse Job Description included but was not limited to; Performs rounds to ensure resident needs are being met and personnel are performing their assigned duties.A review of the facility provided, Certified Nursing Assistant Job Description included but was not limited to; Under Major Duties and Responsibilities: Assists residents with or performs activities of daily living for resident in accordance with care plans and established policies and procedures. Under section Additional Assigned Tasks: Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with .state/federal regulations and guidelines. NJAC 8:39-27.1(a), 27.2(g)

Based on interview and record review, it was determined that the facility failed to clarify conflicting physician's orders for lactulose (a medication used to treat chronic constipation and hepatic encephalopathy: a brain condition caused by liver disease).The deficient practice was identified for 1 of 1 resident (Resident #5) reviewed for Dialysis and was evidenced by the following:On 2/26/2026 at 11:29 AM, the surveyor interviewed Resident #5, who stated they received dialysis in the morning on Monday, Wednesday, and Friday. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #5.A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; gastrointestinal hemorrhage (bleeding that occurs in the intestinal tract), type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and high blood sugar levels), and end stage renal disease (the final stage of chronic kidney disease where kidneys can no longer function to sustain life without treatment).A review of the resident's quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 01/08/2026, included the resident had a Brief Mental Status score of 15 out of 15, which indicated no cognitive impairment. Further review revealed the resident received dialysis.A review of the resident's Individual Comprehensive Care Plan included a focus area for potential for constipation dated 10/03/2025. Interventions included to follow facility bowel protocol for bowel management. Another focus area for nutrition dated 10/07/2025 revealed a goal of regular bowel movements; A focus area for history of constipation dated 10/07/2025, revised 02/26/2026 revealed an intervention to follow bowel habits; and a focus area for hemodialysis related to renal failure dated 10/03/2025.A review of the Order Summary Report revealed the following physician's order (PO):-A PO dated 10/02/2025 for No lactulose for dialysis residents;-A PO dated 02/02/2026 for Resident Dialysis M-W-F 6 AM;-A PO dated 11/18/2025 for lactulose encephalopathy oral solution, give 10 grams by mouth every 24 hours as needed (PRN) for constipation. A review of the Medication Administration Record (MAR) revealed the administration of the PRN lactulose encephalopathy oral solution on 12/07/2025 at 9:48 AM coded with E (effective).A review of the progress notes in the EMR revealed a physician note dated 10/31/2025 that included .lactulose as needed. There was no record of a progress note related to the administration of the PRN lactulose on 12/07/2025.On 02/27/2026 at 9:16 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who was caring for Resident #5. LPN #1 reviewed the POs for both No lactulose and PRN lactulose. LPN#1 stated, the No lactulose order does not show on the MAR, it was in the ancillary section, and the nurses do not see it or sign for it. LPN#1 further stated For clarification, when someone goes to dialysis, if they cannot have a bowel movement, most of the time they get lactulose because they can't have Milk of Magnesia. Lactulose is an order you get, it's recommended for dialysis residents. LPN#1 reviewed the MAR and confirmed the PRN lactulose was administered on 12/07/2025. LPN#1 then stated, that order for No lactulose shouldn't be there.On 02/27/2026 at 9:26 AM, in the presence of the surveyor, the Director of Nursing (DON) reviewed the POs for Resident #5. The DON stated the No lactulose order came in a batch order upon admission for all residents and orders should be specified after that. The DON confirmed that the resident also had a PO for PRN lactulose. The DON then stated, I can say that is a contraindication to have an order for No lactulose and an order for lactulose.On 02/27/2026 at 11:31 AM, during a telephone interview with the surveyor, the physician stated I don't typically order lactulose based on loose bowel movements causing dehydration. That batch order is not something I normally order myself.On 03/02/2026 at 9:32 AM, the surveyor interviewed the physician over the telephone who confirmed he did order the PRN lactulose.On 03/03/2026 at 9:45 AM, in the presence of the survey team, the Regional Nurse Consultant (RNC) stated The facility has a standing order for all dialysis residents for No lactulose, initiated on admission, and reviewed by the physician. The physician acknowledged this order. The RNC further stated The resident was receiving lactulose nightly at the hospital. Upon transfer, the order was changed to PRN and approved by the physician during reconciliation. The RNC confirmed the batch No lactulose order should have been discontinued upon admission by the nurse who received the resident and reconciled the orders with the physician.A review of the facility provided, Licensed Practical Nurse Job Description included but was not limited to; Major Duties and Responsibilities: Prepares and administers medications as per physicians' orders . Additional Assigned Taks: Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with . state/federal regulations and guidelines. NJAC 8:39-23.2(b)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a controlled medication (Methadone)(used for opioid dependence treatment) was stored with the appropriate labeling and the coordinating controlled drug sheet (CDS)(a record of inventory) was altered appropriately for one (1) of three (3) medication carts inspected. The deficient practice was evidenced by the following: On 2/26/26 at 11:10 AM, the surveyor inspected the B wing front hall medication cart, in the presence of the Licensed Practical Nurse (LPN #1). The surveyor observed four (4) Methadone liquid bottles labeled for Resident #68 in a cellophane bag. The bag had a label with unsampled Resident #1's name crossed out with pen. LPN #1 acknowledged that the label was not for Resident #68 and was crossed out. LPN #1 was unable to speak to why the bag was not properly labeled for Resident #68. At that time, the surveyor requested the corresponding controlled drug sheet (CDS) for the Methadone for Resident #68. LPN #1 removed the Chain of Custody Record/External Facility (a form generated by a clinic indicating the total number of doses for a specific resident given to the facility to keep inventory of a controlled medication) from a binder and signed the form. Then, the surveyor observed LPN #1 go to the nursing station and returned with white correction fluid and proceeded to use the correction fluid to cover her signature on the form. LPN #1 explained that she had mistakenly signed for the date 2/27/26 indicating she had administered Methadone on 1/27/26. LPN #1 was unable to speak to why she signed the form and thought she was able to use the correction fluid on controlled drug records. On 2/26/2026 at 11:17 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN), who stated she was responsible for going to the clinic every week and obtaining the Methadone bottles for Resident #68. The UM/LPN reviewed the Chain of Custody Record/External Facility for Resident #68. UM/LPN stated she had signed the form when she picked up the Methadone and the form was used to keep inventory and document when the Methadone was administered and by whom. The UM/LPN acknowledged that there was white correction fluid on the form for a signature for 1/27/26 and under the section Name of Staff Administering Dose. The UM/LPN stated white correction fluid was not allowed to be used on the form. The UM/LPN added she thought the clinic used the white correction fluid on the form under the section Name of Staff Administering Dose. The UM/LPN explained the proper procedure was if the nurse made a mistake signing the form, they would draw a line with a pen through the signature name, initial and add a description of the error. At that time, the UM/LPN went to the medication cart and reviewed the bag labeled for unsampled resident #1 containing Resident #68's Methadone bottles. The UM/LPN acknowledged the bag was labeled for unsampled Resident #1 and the name was crossed out with a pen. The UM/LPN stated the nurses had put Resident #68's Methadone bottles in a used bag meaning that the bag originally contained medication for unsampled Resident #1 and was reused to store the Methadone bottles for Resident #68. The UM/LPN added unsampled resident #1 was also on Methadone. The UM/LPN stated each bag should be labeled for the appropriate resident. The UM/LPN also stated that she had plenty of cellophane bags in the facility to make sure the label was appropriate and could not speak to why a bag for another resident was used and label crossed out. The surveyor reviewed the Order Summary Report for Resident #68 which reflected an active physician's order (PO) for Methadone HCl (hydrochloride) Oral Concentrate 10 MG (milligrams)/5 ML (milliliters) Give 132 MG by mouth one time a day for Opioid dependence. The surveyor reviewed the Order Summary Report for unsampled Resident #1 which reflected an active PO for Methadone HCl Oral Concentrate 10 MG/ML via G-Tube (gastrostomy tube-tube inserted into the stomach) one time a day every Mon, Tue, Thu, Fri, Sat for Opioid dependence. On 2/27/2026 at 10:05 AM, the surveyor interviewed the Director of Nursing (DON) regarding controlled drug procedures. The DON explained that each UM was responsible for picking up Methadone on a weekly basis and ensuring the inventory forms were accurate. The DON added that he had cellophane bags at the facility for the purpose of keeping the Methadone bottles together for each resident. The DON added that the bag should be properly labelled for each resident. On 2/27/26 at 11:42 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone. The CP stated unit inspections were conducted monthly which included spot checking the medication carts and controlled drugs. The CP stated the label on the medication bag should match the name of the resident's medication in the bag. On 3/3/26 at 9:44 AM, the survey team met with the administrative team. The Regional Clinical Nurse stated education was provided to the nurses to properly store medications and not to cross out names on a label and correction fluid was not to be used. The DON added correction fluid was removed from all units. A review of the facility policy Medication Administration dated reviewed/revised 10/20/25, provided by the DON, revealed Compare medication source (bubble pack, vial, etc.) with MAR (medication administration record) to verify resident name, medication name, form, dose route, and time. A review of the facility policy Medication Administration dated as reviewed/revised 3/17/25, provided by the DON, revealed the policy of the facility was to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. In addition, The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient specific-narcotic dispensed from the pharmacy. NJAC 8:39-29.4(g)(h)(k), 29.6(b)(1), 29.7(c)

Based on observation, interview, record review, and review of pertinent facility records, it was determined that the facility failed to ensure infection control practices were implemented by staff not appropriately donning(put on) and doffing(remove) Personal Protective Equipment (PPE), in accordance with accepted national standards, Centers for Disease Control and Prevention (CDC) guidelines, before and after exiting a resident's room, (Resident #109), who was on Transmission Based Precautions (TBP) due to Methicillin-resistant Staphylococcus aureus (MRSA) (a type of bacteria resistant to common antibiotics that can be transmitted through direct contact) and perform hand hygiene to prevent the spread of infection, on one (1) of three (3) units . The deficient practice was evidenced by the following: According to the U.S. CDC guidelines for Transmission-Based Precautions dated 4/3/2024, indicated to Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. On 2/25/26 at 10:08 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse(UM/LPN), who stated that Resident #109 was on TBP but would have to check if it was MRSA or MSSA (methicillin-susceptible Staphylococcus aureus in the bloodstream).On 2/25/26 at 10:18 AM, the surveyor observed, from the hallway, Resident #109's closed bedroom door with a reddish color sign from the New Jersey Department of Health Communicable Disease Services on the door which indicated CONTACT AND DROPLET PRECAUTIONS ARE IN PLACE. STOP EVERYONE MUST: CLEAN THEIR HANDS, INCLUDING BEFORE ENTERING AND WHEN LEAVING THE ROOM. STOP PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another patient. Make sure eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit.On 2/25/26 at 10:57 AM, the surveyor observed the Physical Therapist (PT) in Resident #109s room. The PT was not wearing PPE, a gown or glove. The surveyor heard from the hallway outside the resident's room, the PT talking with the resident. The PT came out of the resident's room and closed the door. At that time, the surveyor interviewed the PT. The surveyor, with the PT, reviewed the signage on the resident's door. The PT stated that contact precautions meant that anyone entering the room would have to wear a gown and gloves before entering and discard before leaving the room. The PT acknowledged that she had not donned or doffed a gown and/or gloves prior to going into the room. The PT added she was unsure if the signage was for Resident #109 and thought it was for a different resident. The PT also stated that Resident #109 had an infection in their hand and was on an IV (intravenous) antibiotic, so the resident was on Enhanced Barrier Precautions (EBP) meaning a gown and gloves were necessary only if high contact resident care was being provided.The surveyor reviewed the electronic medical record for Resident #109.A review of the admission Record reflected diagnoses which included, but were not limited to; sepsis due to MSSA and acute osteomyelitis, right hand.A review of the resident's interdisciplinary comprehensive Care Plan Report dated as initiated 2/2/26 and revision 2/12/26 revealed a focus area, Resident #68 requires EBP R/T (related) to IV line. Another focus area with a date initiated 1/30/26 and revision date 2/12/26 indicated Resident #109 is on antibiotic therapy r/t Vancomycin (an antibiotic) for MRSA infection from 2/17/26-2/17/26.A review of the Order Summary Report indicated a Physician's Order (PO) with a start date 2/17/26 for Vancomycin HCL(hydrochloride) solution reconstituted 1000 milligrams/200 milliliter (ML),Use 1 gram intravenously one time a day for MRSA until 2/27/26. An additional PO with a start date 2/18/26 indicated Infection Precautions-contact for MRSA every shift for CONTACT PRECAUTIONS FOR MRSA.A review of the February 2026 Medication Administration Record (MAR) revealed nurses were signing a PO dated 2/2/26 with a discontinuation date of 2/18/26 for Resident requires EBP for a diagnosis of a IV line every shift for IV line.On 2/26/26 at 10:43 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that they were familiar with Resident #109. CNA #1 stated the resident was independent and was able to do their own care, but she would bring the resident linens, meal tray and anything they needed. CNA #1 added she would wear a gown and gloves if she needed to provide care or assist with care.On 2/26/26 at 11:40 AM, the surveyor attempted to interview Resident #109. The surveyor knocked on the resident's room door that had the same signage observed prior. The resident opened the door and declined to be interviewed and shut the door.On 2/26/26 at 12:13 PM, the surveyor observed CNA #2 enter Resident #109's room and then come out of the room with a meal tray and closed the door. The surveyor had not observed CNA #2 put on a gown and gloves when entering Resident #70's room or perform hand hygiene after exiting the room. At that time, the surveyor interviewed CNA #2, who stated she was not assigned to Resident #109 and was just picking up a lunch tray that was finished. The surveyor, with the CNA #2, reviewed the signage on the resident's door. CNA #2 stated she was unsure if the resident was on contact precautions but knew that the signage meant they must have some kind of infection and that a gown and gloves were required before going into the room and removed before coming out. CNA #2 acknowledged she had not put on PPE or performed hand hygiene.On 2/26/26 at 12:14 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated Resident #109 was on EBP and she was required to wear a gown and gloves if providing care. LPN #1 also stated contact precautions meant anyone had to put on a gown and gloves before entering the room and before leaving the room, had to remove the gown and gloves and perform hand hygiene.At that time, the surveyor, with LPN #1, reviewed the signage on the closed door of Resident #109's room. LPN #1 stated that she was confused and had to check with the Unit Manager/LPN.On 2/26/26 at 12:18 PM, the surveyor, with the UM/LPN and LPN #1, reviewed the signage on the closed door of Resident #109's room. The UM/LPN stated the signage meant before entering the room, a gown and gloves were required even if dropping off or picking up a meal tray. The UM/LPN added she was unsure if the resident was on contact precautions because the resident had a wound that was covered, and the IV antibiotic will be completed tomorrow. The UM/LPN stated she would have to check with the Director of Nursing (DON).On 2/26/26 at 1:02 PM, the surveyor interviewed the Rehab Director/Speech Therapist (RD/ST) who stated every morning there was a meeting with department heads and any resident on TBP was discussed. The RD/ST added signage was on the resident's door to alert staff what PPE was required, and the staff should check the signage. The RD/ST stated she did not have a list of the residents who were on TBP but off the top of her head knew of two residents whose names she stated, which neither was Resident #109. The surveyor then asked if Resident #109 was on TBP and the RD/ST explained she could check the electronic record. After reviewing the electronic record for Resident #109, the RD/ST stated the resident was on contact precautions. The RD/ST explained a resident on contact precautions usually had therapy in their room and a gown, gloves and a mask were required. The RD/ST added there were circumstances a resident would be allowed in the gym as the only resident in the gym and equipment cleaned immediately after. On 2/26/26 at 1:12 PM, the surveyor interviewed the UM/LPN who stated she was contacting the infection disease physician for Resident #109. The UM/LPN confirmed Contact precautions signage was on the resident's door and should be followed. The UM/LPN added the resident was not on droplet precautions and acknowledged both were listed on the signage. On 2/27/26 at 11:42 AM, the surveyor interviewed the Infection Preventionist (IP/LPN) who stated any resident on contact precautions was usually known upon admission including what type of infection they had. The IP/LPN added she has educated the staff on what to do for contact precautions which included do not step a pinky toe in that room without full PPE meaning a gown and gloves were required to be worn before entering the resident's room and removed before exiting the room and perform hand hygiene. The IP/LPN also stated Resident #109 had been on contact precautions for MRSA in the bloodstream and was being discharged today. The IP/LPN acknowledged that she was following CDC guidelines. The IP/LPN stated there may have been confusion because the resident was on another wing then transferred to their current room and had MSSA in a wound and the wound had closed so the staff may have thought the resident was on EBP. The IP/LPN added the resident still had MRSA in the blood and was on an antibiotic which was completed today. The IP/LPN also stated the Rehab department was mistaken and should have been following contact precautions in the resident's room. The IP/LPN had a list of residents on TBP which indicated Resident #109 was on Contact Precautions and the reason was IV line Contact MRSA.On 3/3/26 at 9:44 AM, the survey team met with the facility administrative team. The Regional Clinical Nurse (RCN) stated the staff were re-educated on proper infection control practices. The RCN and DON acknowledged Resident #109 was on contact precautions during their stay as designated by the signage.A review of the facility policy titled Isolation-Categories of Transmission-Based Precautions revised/reviewed 1/2022, provided by DON, revealed for Contact Precautions gloves and a gown were to be worn before entering the room and removed before leaving the room and perform hand hygiene.A review of the facility policy titled Transmission-Based (Isolation) Precautions dated as reviewed/revised 10/14/25, provided by the DON, revealed It is the policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. The policy had the following definitions:Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Transmission-based precautions (a.k.a.Isolation Precautions) refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact and droplet) in order to prevent or control infections.The policy had an explanation and compliance guidelines which included but not limited to;1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission.4. Residents on transmission-based precautions should remain in their rooms except for medically necessary care.e. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room, wing, or facility-wide. Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage.10. Contact Precautions-a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment.c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment.Further review of the policy included a table for Recommendations for Personal Protective Equipment (PPE) which indicated for Contact Precaution, gloves was the type of PPE required with recommendations Whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). [NAME] gloves upon entry into the room or cubicle. In addition, for Contact Precaution, gown was the type of PPE required with recommendations Whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. [NAME] gown upon entry into the room or cubicle.Also, the policy included a table for Type and Duration of Transmission-Based Precautions Recommended for Selected Infections and Conditions indicated for the infection/condition of Multidrug-resistant organisms (MDROs), infection or colonization (i.e. MRSA.) the precaution was standard/contact based on local, state, regional, or national recommendations. Contact Precautions recommended in settings with evidence of ongoing transmission or in settings with increased risk for transmission or wounds that cannot be contained by dressings.NJAC 8:39-19.4 (a) (1, 2)(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure the narcotic count was completed on multiple days and shifts for August 2024 for 3 of 3 medication carts reviewed; b.) ensure accurate accountability for individual controlled medications for 3 of 3 medication carts reviewed; and c.) ensure the required Federal narcotic acquisition forms (DEA 222 forms) were dated and signed by the Medical Director as of the day it was submitted for filling for 1 of 1 forms provided. The deficient practice was evidenced by the following: 1. During medication storage review on 8/26/24 at 9:55 AM, the surveyor in the presence of the Registered Nurse (RN), reviewed the B-Wing nursing unit's Medication Cart #2's August 2024 Narcotic and Controlled Drug Sign-in Sheet (shift-to-shift accountability count sheet for controlled substance and narcotics (narc) signed by the incoming and outgoing nurses each shift) which revealed the following: The narcotic counts were blank for the incoming nurse Total # of Narcs for the following shifts: All shifts on: 8/1; 8/2; 8/5; 8/10; 8/13; 8/15; 8/16; 8/17; 8/18; and 8/23. For the day shift (7:00 AM to 3:00 PM) on: 8/3; 8/4; 8/6; 8/7; 8/11; 8/12; 8/14; and 8/26. For the evening shift (3:00 PM to 11:00 PM) on: 8/3; 8/6; 8/7; 8/8; 8/12; 8/14; 8/24; and 8/25. For the overnight shift (11:00 PM to 7:00 AM) on: 8/11; 8/12; 8/19; 8/20; 8/21; 8/22; 8/24; and 8/25. The narcotic counts were left blank for the outgoing Total # of Narcs for the following shifts: All shifts on: 8/1; 8/2; 8/5; 8/10; 8/13; 8/14; 8/15; 8/16; 8/17; 8/18; and 8/23. For the day shift on: 8/3; 8/4; 8/6; 8/7; 8/9; 8/11; 8/12; 8/20; and 8/26. For the evening shift on: 8/3; 8/6; 8/7; 8/8; 8/12; 8/22; 8/24; and 8/25. For the overnight shift on: 8/9; 8/11; 8/19; 8/21; 8/22; 8/24; and 8/25. Nursing signatures were missing for Incoming Nurse evening shift on 8/9 and Outgoing Nurse for 8/22 evening shift. A further review of the Individual Patient Controlled Substance Administration Record (declining inventory sheet; declining inventory log used to document individual resident-controlled substance administration) revealed the following: Resident #275's declining inventory sheet for oxycodone 10 milligram (mg), a pain medication, the nurse did not sign the dose for 8/20/24 at 5:25 PM. Resident #62's declining inventory sheet for morphine sulfate 100 mg/5 milliliter (mL), a pain medication, the nurse did not sign the dose for 8/18/24 at 9:00 PM and 8/19/24 at 10:00 PM. At that time, the RN confirmed that the narcotic shift-to-shift log and the declining inventory sheets were missing nurses' signatures and there should not be. On 8/26/24 at 10:37 AM, the surveyor in the presence of the Unit Manager/Licensed Practical Nurse (UM/LPN), reviewed the C-Wing nursing unit's Medication Cart #1's August 2024 Narcotic and Controlled Drug Sign-in Sheet which revealed the following: The narcotic counts were blank for the incoming nurse Total # of Narcs for the following shifts: All shifts on: 8/1; 8/2; 8/3; 8/4; 8/5; 8/6; 8/7; 8/8; 8/9; 8/10; 8/11; 8/12; 8/13; 8/14; 8/15; 8/16; 8/17; 8/18; 8/19; 8/20; 8/22; 8/23; and 8/25. For the day shift on: 8/24 and 8/26. For the evening shift on: 8/21. For the overnight shift on: 8/21. The narcotic counts were left blank for the outgoing Total # of Narcs for the following shifts: All shifts on: 8/1; 8/2; 8/3; 8/4; 8/5; 8/6; 8/7; 8/8; 8/9; 8/10; 8/11; 8/12; 8/13; 8/14; 8/15; 8/16; 8/17; 8/18; 8/19; 8/20; 8/22; 8/23; and 8/25. For the day shift on: 8/24. For the evening shift on: 8/21. For the overnight shift on: 8/21 and 8/24. Nursing signatures were missing for 8/25 Incoming Nurse evening and Outgoing Nurse evening shift. Further review of the Individual Patient Controlled Substance Administration Record revealed the following: Resident #46's declining inventory sheet for morphine sulfate solution 100 mg/5 mL was missing the date, time, and Nurse Administering signature for the fourth dose administered with a remaining balance of 28.5 mL. At that time, the UM/LPN acknowledged that there should be no missing signatures or documentation on any of the narcotic logs. On 8/26/24 at 11:11 AM, the surveyor in the presence of the Licensed Vocational Nurse (LVN), reviewed the A-Wing nursing unit's Medication Cart #1's August 2024 Narcotic and Controlled Drug Sign-in Sheet which revealed the following: The narcotic counts were blank for the # of count sheets for the following shifts: For the day shift on: 8/12; and 8/25. For the evening shift on: 8/5; 8/11; and 8/25. For the overnight shift on: 8/1; 8/2; 8/4; 8/5; 8/8; 8/10; 8/11; 8/12; 8/15; 8/21; 8/24; and 8/25. The column labeled is count correct? was blank on the following shifts: For the evening shift on: 8/25. For the overnight shift on: 8/5; 8/9; 8/15; 8/22; and 8/23. Nurse's Signature Going off Duty was blank for 8/24 day shift and pre-signed for 8/26 evening shift. Further review of the Individual Patient Controlled Substance Administration Record revealed the following: Resident #11 declining inventory sheet for alprazolam 0.5 mg (a medication used to treat anxiety) was missing the Nurse Administering signature for the dose administered on 8/5/24 at 9:00 AM, and the 8/26/24 at 10:00 AM dose the LVN administered. Resident #70's declining inventory sheet for clonazepam 1 mg (seizure medication) was not signed by the LVN for the dose administered on 8/26/24 at 9:00 AM. Resident #28's declining inventory sheet for lorazepam 0.5 mg (seizure medication) was not signed by the LVN for the dose administered on 8/26/24 at 9:00 AM. At that time, the LVN acknowledged that there should be no missing documentation on the narcotic logs. The LVN stated that she did not sign the individual declining inventory sheets that morning because she got busy, and I would come back to them. The LVN also acknowledged that she had pre-signed the shift-to-shift count log for the end of her shift, and that was not the appropriate protocol. The LVN confirmed that the incoming and the outgoing nurses were to complete the count and sign together at the end of each shift. On 8/26/24 at 12:22 PM, the surveyor interviewed the Acting Director of Nursing (DON), who stated that the narcotic count for each medication cart was to be completed at each shift hand off by the incoming and the outgoing nurses. The Acting DON confirmed that there should be no missing documentation on narcotic logs, and there should also be no pre-signed fields, and the if it was not documented, it was considered not done. The Acting DON further stated that declining inventory logs were to be completed by the administering nurse for each dose at the time the medication was dispensed to keep accountability of the narcotics administered. 2. On 8/27/24 at 10:11 AM, the surveyor in the presence of the Acting DON and the survey team, reviewed the facility provided DEA 222 forms which revealed that order form number 240132045 had been pre-signed by the facility's Medical Director prior to submission to the provider pharmacy for filling. At that time, the Acting DON confirmed that the DEA 222 form should not have been pre-signed by the physician. The facility was unable to provide a policy regarding the completion of the DEA 222 form. A review of the facility's Controlled Substances policy dated updated April 2024, included .nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services . The policy did not include resident's declining inventory sheets. NJAC 8:39-29.7(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure psychiatric recommendations from 2/7/24 and 7/31/24, to check therapeutic levels of medication used to treat bipolar, were obtained in a timely manner. The deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #68), and was evidenced by the following: On 8/19/24 at 11:18 AM, the surveyor observed Resident #68 sitting in the dayroom during activities. They were unable to be interviewed. On 8/22/24 at 10:08 AM, the surveyor reviewed the medical record for Resident #68. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included Parkinson's disease; dementia; generalized anxiety disorder; failure to thrive (syndrome of weight loss, decreased appetite and nutrition); major depressive disorder, and bipolar. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/1/24, reflected the resident had a brief interview for mental status (BIMS) score of a 3 out of 15; which indicated a severely impaired cognition. A further review included the resident took antipsychotic and antidepressant medications daily. A review of the Medication Review Report included a physician's order dated 12/4/23, for lithium carbonate (a medication used to treat bipolar) 150 milligram (mg) capsule; give one capsule by mouth at bedtime for manic depression. A review of the individualize comprehensive care Plan (ICCP) included a focus area dated 10/24/23, that the resident used antidepressant medication fluvoxamine and lithium carbonate with regards to depression. Interventions included to administer medications as ordered. A review of the Psychiatry Progress Note dated 2/7/24, included for the plan to repeat lithium level (a laboratory (lab) test to determine the therapeutic levels of lithium in the blood). A review of the corresponding lab reports revealed that the lithium levels were not tested until 3/25/24. A review of the Progress Notes from 2/7/24 until the labs were completed on 3/25/24, did not include a note for the delay in labs. A review of the Psychiatry Progress Note dated 7/31/24, included for the plan to check lithium levels. A review of the corresponding lab reports did not include a lithium test was completed. A review of the Progress Notes included a Nurse's Note dated 8/1/24 at 1:51 PM, that resident was seen by psychiatry at beside with Resident Representative (RR) present with a new recommendation to increase Seroquel (antipsychotic medication). The note did not include to check the lithium levels. On 8/22/24 at 12:48 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN), who stated after a resident was seen by Psychiatry, the nurse reviewed the consultation (consult), and if there were any new recommendations, the nurse called the resident's physician to tell them. The UM/LPN stated the physician was notified right away, and the nurse documented it. The UM/LPN stated if labs were recommended, the labs were usually ordered for the next day. The UM/LPN confirmed Resident #68 took lithium, and the physician ordered labs for the therapeutic levels she thought quarterly, but the labs were completed when ordered. At that time the surveyor reviewed with the UM/LPN the resident's Psychiatry Progress Notes from 2/7/24 and 7/31/24, which both recommended to check lithium levels. The UM/LPN confirmed the only labs in the electronic medical record were from 3/25/24, but she stated she would check to see if any labs were done and not in the electronic medical record. On 8/22/24 1:23 PM, the surveyor re-interviewed the UM/LPN confirmed the only lab report for the lithium level being checked was from 3/25/24. The UM/LPN stated that she had to call the physician to see if they wanted the resident's lithium levels checked, that it was usually done quarterly. On 8/22/24 at 1:52 PM, the surveyor interviewed the Acting Director of Nursing (DON), who stated after a resident had a consult, the nurse reviewed the consult with the resident's physician as soon as possible, and documented in the Progress Notes if the physician agreed or disagreed with the recommendation. At that time the surveyor with the Acting DON reviewed Resident #68's Psychiatry Progress Notes from 2/7/24 and 7/31/24, and the DON confirmed the physician should have been notified immediately. On 8/27/24 at 9:50 AM, the Acting DON in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team, acknowledged that there was no documentation that the nurses notified the physician after the resident's consults, and that the physician either agreed of disagreed with the recommendation to check the lithium levels. The Acting DON confirmed the only labs for lithium levels that were performed this year was on 3/25/24. A review of the facility's Laboratory Services and Reporting policy dated revised April 2024, included the facility must provide or obtain laboratory services to meet the needs of the residents; the facility is responsible for the timeliness of the services . A review of the facility's Physician Orders policy dated revised December 2023, included Consultant Recommendations/Orders: in all cases, the attending physician must be notified of the order and approve per state regulation; findings and recommendations will be documented on the Consultation Form; the nurse will notify the physician of findings and recommendations; the attending physician, if in agreement, will order the specific treatments as outlined by the consultant. NJAC 8:39-27.1(a)

Based on interview and observation, it was determined that the facility failed to a.) ensure staff did not use their cell phones in resident care areas and while performing resident care; and b.) ensure staff did not speak in a non-English language while rendering care to English-speaking residents. This deficient practice was identified by 4 of 4 residents during the Resident Council group meeting (Resident #9, #14, #57, and #79) and evidenced by the following: On 8/21/24 at 10:02 AM, the surveyor conducted a resident group meeting with four residents who were alert and oriented and selected by the facility to attend the group meeting. All four residents complained that staff, both certified nursing aides (CNAs) and nurses were on their phones and some spoke in a foreign language on the phone when providing resident care. Resident #14 and Resident #57 stated that nurses were on their bluetooth earpieces on the phone when preparing and administering medications, and they both were given incorrect medications that they refused to take. All four residents agreed it was an issue, and the facility was aware of it, but nothing was done. All four residents felt that since COVID, there have been staffing shortages, so the facility let the staff in the facility do whatever they wanted with no repercussions. On 8/21/24 at 11:59 AM, the surveyor interviewed the facility's Social Worker (SW), who stated that residents have complained about staff on their cell phones, and she conducted formal education as well with staff. The SW stated that staff was not to be on their cell phone. At that time, the surveyor requested a copy of the facility's cell phone policy and inservice conducted. On 8/21/24 at 12:25 PM, the surveyor observed CNA #1 in the hallway with a bluetooth earpiece in her ear. The surveyor did not observe CNA #1 actively in a phone conversation. On 8/21/24 at 1:03 PM, the surveyor reviewed the Inservice 7/25/24, provided by the SW, which included no cell phone, headphones or ear buds allowed on the floor; must use in breakroom, and only speak English around English-speaking residents. On 8/26/24 at 10:18 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated staff were reminded to speak in English in resident care areas and resident rooms. The LNHA stated that staff were expected to not use personal phones in resident care areas, as well as staff should not be using bluetooth earpieces, even if they were not providing resident care. The LNHA stated there were no cell phones allowed on the floor or during care because it was disrespectful to the residents. On 8/27/24 at 9:50 AM, the Acting Director of Nursing (DON) in the presence of the LNHA and survey team, stated that the residents had a concern with staff cell phone usage that the LNHA addressed in July. The LNHA acknowledged it was still a concern. The surveyor asked if the facility disciplined staff for using their cell phones, and the LNHA stated not since the meeting but the facility had in the past. The surveyor asked what happened to the staff who was found using their phone, and the LNHA stated the facility only suspended staff during investigations for abuse, and the staff would be written up for a cell phone. The surveyor requested a copy of any staff write-ups for cell phone usage. No additional information was provided. A review of the facility's Resident Rights policy dated updated April 2024, included federal and state laws guarantee certain basic rights to all residents of this facility. These rights include resident's right to include but not limited to: .to be treated with respect, kindness, and dignity .have facility respond to his or her grievances . A review of the untitled facility provided policy dated January 2022 Edition, included Personal Electronic Device .workplace use of these devices can raise a number of issues involving safety, security, and privacy .employees should conduct personal business during meal breaks and other rest periods. This includes the use of personal communication devices .violation of this policy may result in discipline, up to and including termination of employment. NJAC 8:39-4.1(a)12

Based on interview and review of pertinent facility documents, it was determined that the facility failed to document complete and appropriate information on the New Jersey Universal Transfer Form (UTF) to communicate with the emergency room (ER) where a resident was being transferred, or to have a policy and procedure for UTF. This deficient practice was identified for 1 of 2 residents reviewed for hospitalization (Resident #100), and was evidenced by the following: Reference: NJ.gov: https://www.nj.gov/health/forms/hfel-7instr_1.pdf: INSTRUCTIONS FOR COMPLETING THE NEW JERSEY UNIVERSAL TRANSFER FORM dated [DATE], The purpose of the New Jersey Universal Transfer Form: A form that communicates pertinent, accurate clinical patient care information at the time of a transfer between health care facilities/programs. It conveys the patient information required under federal regulations and conveys specific facts that the physician and nurse need to begin caring for a patient. The word patient is used throughout the form, but refers to resident/client or the terminology used by a specific facility or program. Complete all boxes #1 - 29. On 8/27/24 at 10:30 AM, the surveyor reviewed the medical record for Resident #100. A review of the Admission Record face sheet (an admission summary) revealed the resident had diagnoses which included but were not limited to; unspecified psychosis, depressive disorder, and somatoform (health related anxiety and mental disorder) disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 6/19/24, reflected the resident had a brief interview for mental status (BIMS) score of 5 out of 15, indicating a severe cognitive impairment. A further review of Active Diagnoses included non-Alzheimer's dementia, depression, and schizophrenia. A review of the Order Summary Report for 7/1/24 to 7/30/24, the physician's order (PO) dated 7/23/24, for contact and droplet precautions . for diagnosis of COVID-19. A review of the individualized comprehensive care plan (ICCP) included but not limited to the focus areas of ; Advanced Directives Full code; potential to be verbally aggressive . threaten staff with physical harm with interventions which included, when [Resident # 100] became agitated: intervene before agitation escalates [ .]; an elopement risk/wanderer; a fall risk and as having had an actual fall 6/11/24; dated 7/23/24, requires isolation precautions related to COVID-19 with an intervention to educate staff, resident, family and visitors .of precautions. A review of the Progress Note (PN) dated 7/23/24 at 9:35 AM, indicated Resident #100 had begun shouting, get me an ambulance; resident became agitated and pounding fists into nursing station. The nurse called emergency services, and the resident was taken to [name redacted] hospital emergency room via ambulance. A review of the PN dated 7/23/24 at 6:43 PM, revealed that Resident #100 had returned to the facility. A review of the PN dated 7/24/24 at 7:24 AM, indicated Resident #100 was uncooperative, unable to be redirected, using vulgar language and threatening staff with physical abuse and expressing intent to elope the secured unit. Resident was placed on one-to-one observation. A review of the PN dated 7/24/24 at 11:18 AM, the Social Worker documented that Resident #100 still had behaviors of threatening staff, assault them and threatening to kill them and threatening to break the window to escape. Resident was transported to the emergency room . A review of the two UTFs, which documented on the top of the form Items 1 - 29 must be completed revealed the following: The first undated form revealed the reason for transfer as danger to others and self, elopement risk and the following areas were left blank: #2 date and time; #6 code status; #9 primary diagnosis including mental health diagnosis (if applicable); #12 isolation precautions with option for none; #18 personal items sent with patient with option for none; #20 at risk alerts with option for none; #21 mental status; #22 PASRR (pre-admission screening and resident review which indicates mental illness status); #23 function with option self; #25 bowels; #26 bladder; #27 no phone number of the facility sending the resident out for evaluation; and #29 who completed the UTF form. The first UTF indicated that only Resident #100's Face Sheet was attached and no other documents. The second undated form revealed the following areas were left blank: #1 transfer to what facility; #2 time of transfer; #6 code status; #8 reason for transfer; #9 primary diagnosis; #12 isolation precautions with option for none; #18 personal items sent with patient with options for none; #19 attached documents; #22 PASRR; #27 sending facility contact information; and #29 who completed the UTF form. On 8/26/24 at 11:13 AM, the surveyor interviewed the Infection Preventionist/Licensed Practical Nurse (IP/LPN), who stated if a resident was being sent out to the hospital, the staff completed the transfer form [UTF]. The IP/LPN further stated that the staff informed the transport staff verbally and that it was important in case the [hospital] staff did not get to the resident right away. On 8/26/24 at 1:05 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that the facility had no policy or procedure for the staff to follow regarding the use of the UTF. The surveyor reviewed the two undated UTFs with the LNHA, who stated that the staff did not have to fill out all areas of the form regardless of the instructions on the form, but to just to fill out only relevant areas. On 8/27/24 at 9:50 AM, the LNHA in the presence of the Acting Director of Nursing (DON) and survey team stated that the medical records department, or the unit clerk were responsible to upload the UTF to the electronic medical record, but that was not done immediately. At that time, the Acting DON stated that the nurse who was sending the resident out was to ensure the UTF was completed prior to the resident leaving. A review of the facility provided policy, Transfer or Discharge, Emergency dated revised 12/1/22, .4.d. Prepare a universal transfer form to send with the resident . NJAC 8:39-4.1(a)31

Complaint NJ #:171611 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with a right elbow wound. This deficient practice was identified for 1 of 2 residents reviewed for pressure ulcer (Resident #3), and was evidenced by the following: On 8/19/24 at 11:20 AM, the surveyor observed the Certified Nursing Aide (CNA) outside Resident #3's room putting on personal protective equipment (PPE) prior to entering the room. The CNA stated that the resident was on transmission-based precautions for COVID-19, and staff were required to were PPE prior to entering the room. On 8/20/24 at 1:31 PM, the surveyor reviewed the medical record for Resident #3. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included expressive language disorder (difficulties with verbal and written expression); pressure ulcer of sacral (lower back) region stage 3; and contracture unspecified elbow. A review of the most recent quarterly Minimum Data Set, and assessment tool dated 8/9/24, indicated that the resident had short and long-term memory problems with a severely impaired cognition. A further review revealed the resident had one stage four pressure ulcer (full-thickness and loss that may extend to muscle, bone, tendon, or joint) with pressure reducing devices on chair and bed as well as the resident was on the turn and reposition program. A review of the Order Summary Report included a physician's order (PO) dated 8/16/24, to cleanse right elbow with normal saline solution; apply collagen powder, calcium alginate (wound dressing made from seaweed), and gauze pad and wrap with [brand redacted] antimicrobial woven gauze roll dressing every shift for wound care. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 6/18/21 and last revised on 12/15/23, that the resident had potential for impairment to skin integrity with regards to immobility. Interventions included to check and turn schedule while in bed; educate resident/family/caregivers of causative factors and measures to prevent skin injury; encourage me to off my load heels, and follow facility protocols for treatment of injury. The ICCP did not include the residents actual skin impairment or stage 4 pressure ulcer to right elbow. On 8/22/24 at 1:24 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated she was in charge of completing and updating residents' ICCPs. The UM/LPN stated ICCPs were updated daily for any changes, and the care plan included but not limited to: behaviors, wounds, skin integrity, treatments, medications, fall risks, and preventative care. The UM/LPN stated Resident #3 had a wound to their right elbow, and they were followed by the wound care doctor. The UM/LPN stated that the resident was repositioned frequently and the Physician wanted the resident out of bed limited time because they favored the right side, and put pressure on the right elbow. The UM/LPN continued the Physician also recommended a heel boot as a cushion around the elbow when out of bed to relieve the pressure. At that time, the surveyor with the UM/LPN reviewed the resident's ICCP, and she confirmed the care plan did not include the resident's wound. On 8/22/24 at 1:52 PM, the surveyor interviewed the Acting Director of Nursing (DON) who stated ICCPs were updated quarterly and as needed. At that time, the surveyor and the Acting DON reviewed the resident's ICCP, and the Acting DON confirmed the ICCP did not include the resident's elbow wound, and it should have. On 8/26/24 at 1:33 PM, the Acting DON in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team stated that in the resident's focus area for their pressure ulcer was marked as resolved in July when their sacrum wound healed, but the focus area for the right elbow should have remained. The DON acknowledged there was no active focus area for the right elbow wound at the time of inquiry. The Acting DON confirmed the facility did not have a policy for updating ICCPs, only the Care Plans - Baseline policy that was provided. A review of the facility's undated Care Plans - Baseline policy did not include care plan revisions. NJAC 8:39-27.1(a)

Complaint NJ #: 163699; 172074 Based on observation, interview, and review of facility documents, it was determined that the facility failed to follow professional standards of clinical practice with respect to a.)administering pain medications as ordered for a resident with chronic pain (Resident #48); b.) increasing the dose of two medications for a resident with post traumatic stress disorder in accordance with the physician's orders (Resident #225); c.) following a physician's order for no adhesive tape to a gastronomy feeding tube site (Resident #68); and c.) following their Outbreak Plan and Isolation policy and procedures by not notifying emergency transport staff and receiving facility staff of a resident's isolation precaution status upon the resident's (Resident #100) transfer to the emergency room (ER). This deficient practice was identified for 4 of 38 resident reviewed for professional standards of practice. 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. The surveyor reviewed the policy titled, Administering Medications, the policy had a revision date of 10/2023. The policy statement indicated that medications shall be administered in a safe and timely manner and as prescribed. Number 2 of policy interpretation indicated that medications must be administered in accordance with the orders, including any required timeframe. Number 9 indicated that if a drug is withheld, refused, or given at another time other than scheduled the individual administering the medication will document in the medication administration record. The was evidence was as follows: 1. On 8/21/24 at 9:21 AM, during the 9:00 AM medication pass for Resident #48, the resident asked the Licensed Practical Nurse (LPN #1) why they did not receive their 6:00 AM dilaudid (a drug used to treat moderate to severe pain). The nurse stated she was unsure and would investigate the issue. LPN #1 asked the resident what their pain level was, and the resident responded, seven. (On the numeric pain scale pain of a seven was severe pain.) The surveyor then reviewed the narcotic book with LPN #1 for Resident #48 medications and the last dilaudid was signed out as removed from the cart on 8/20/24 at 12:00 PM. The surveyor then observed LPN #1 do an inventory count of the dilaudid tablets, and it was accurate with the narcotic book meaning no pills were removed after the dose on 8/20/24 at 12:00 PM. On 8/21/24 at 10:10 AM, the surveyor reviewed the medical record for Resident #48. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses that included but were not limited to; multiple myeloma (cancer in the bone marrow) and a back fracture. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/9/24, reflected the resident had a brief interview for mental status (BIMS) score of a 15 out of 15, which indicated a fully intact cognition. A further review revealed the resident was on a scheduled pain regimen. A review of the Medication Administration Record (MAR) revealed the dilaudid scheduled for 8/21/24 at 6:00 AM, the nurse documented it was administered. A review of the Order Summary Report included a physician's order (PO) dated 8/1/24, for dilaudid 4 milligram (mg) oral tablet; to give 1 tablet by mouth three times a day for chronic pain. A review of the individualized comprehensive care plan (ICCP) included the following focus areas: A focus area dated 5/5/22, that the resident used a back brace for support related to pain with an intervention that included to assess for pain every shift. A focus area dated 4/13/21, that the resident had chronic pain related to cancer, chronic pain, and multiple spine compression fractures. Interventions included to administer pain medication as per orders; give 1/2 hour before treatments or care; administer my pain medications per orders and notify the physician if goal was not met with regimen; anticipate the resident's need for pain relief and respond immediately to any complaint of pain; and assess my medications and adjust as needed. On 8/22/24 at 11:00 AM, surveyor interviewed the Acting Director of Nursing (DON) regarding the resident not receiving their dilaudid at 6:00 AM. The Acting DON stated that the resident was sleeping, and the nurse did not want to wake them up, and the nurse meant to sign as not given but she forgot. The Acting DON stated that the facility was going to change the dilaudid's scheduled time so the resident would not need to be woken up. 2. On 8/19/24 at 10:55 AM, during the initial tour of the facility, the surveyor observed Resident #225 in their room in bed. The resident informed the surveyor that the facility ran out of medications sometimes, For one or two days and I don't get my medicine. The resident was not able to tell the surveyor which medications. On 8/22/24 at 10:15 AM, the surveyor reviewed the medical record for Resident #225. A review of the Admission Record face sheet reflected the resident was admitted to the facility with diagnoses which included but were not limited to; subdural hemorrhage (a bleed in the brain), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make breathing difficult), post-traumatic stress disorder (mental condition that develops after someone experiences or witnesses a terrifying or stressful event), anxiety disorder, and depressive disorder. A review of the most recent comprehensive Minimum Data Set (MDS) dated [DATE], that the resident had a BIMS score of 15 out of 15, which meant a fully intact cognition. A review of the August 2024 MAR revealed that the resident had POs dated 8/21/24, for mirtazapine 15 mg tablet; give one tablet by mouth every bedtime for depression and a PO dated 8/21/24, for prazosin 2 mg capsules; give two capsules by mouth every night at bedtime for post-traumatic stress disorder. A review of the Order Summary Report revealed that the PO dated 7/22/24, for mirtazapine 15 mg tablets at bedtime was discontinued on 8/21/24 at 8:23 PM, and a new order for mirtazapine 30 mg at bedtime was ordered to start on 8/21/24 at 10:00 PM. Further review of the physician orders revealed prazosin was increased by the physician from 2 mg to 4 mg at bedtime on 8/21/24 at 8:23 PM, with an order start time of 8/21/24 at 10:00 PM. A review of the corresponding MAR revealed that the medications were not signed as administered by the nurse on 8/21/24. On 8/22/24 at 11:11 AM, the surveyor interviewed Resident #225, who stated they did not get their medications last night like the physician ordered and stated, I have post-traumatic stress disorder. On 8/22/24 at 12:20 PM, the surveyor reviewed the resident's ICCP which included a focus area dated 8/5/24, that the resident used psychotropic medications related to the disease process and had a mood, anxiety, and depressive disorder. On 8/22/24 at 12:25 PM, the surveyor interviewed the Acting DON regarding the resident not receiving the medications, and the Acting DON confirmed that the resident should have received the medications when the order was changed. On 8/22/24 at 12:33 PM, the surveyor conducted a telephone interview with the resident's Physician, who stated that the Psychiatric Nurse Practitioner (Psych NP) made recommendations that they did not agree was best for the resident. The Physician stated that he decided to enter his own orders, which the surveyor confirmed he entered on 8/21/24 at 8:23 PM. The Physician confirmed he wanted the new orders to start that evening. On 8/22/24 at 1:15 PM, the Acting DON provided the surveyor with Progress Notes which revealed the nurse spoke to the Physician on 8/21/24 at 5:29 PM, and that the Physician told the nurse that he would be entering his own orders into the computer. The resident was notified of the Physician's decision at that time. On 8/27/24 at 9:50 AM, the surveyor interviewed the Acting DON regarding Resident #225's medication change, and the Acting DON stated that the supervisor spoke with the Physician and the Physician entered the order, but the order was not confirmed by the nurse until 8/22/24 at 1:00 AM. The surveyor asked the Acting DON if the nurse who was aware of the upcoming change should have followed up with the orders, and the Acting DON confirmed yes. 38080 3. On 8/19/24 at 11:18 AM, the surveyor observed Resident #68 sitting in their wheelchair in the dayroom during activities. At that time, the Resident's Representative (RR) who was with Resident #68, informed the surveyor that the facility's nurses did not communicate with each other. The RR stated that they visited the resident daily, and a few times a week, they noticed adhesive tape on the resident's abdomen for their gastronomy tube (g-tube, a feeding tube surgically inserted into the stomach to provide nutrition). The RR stated the resident could not use adhesive tape because it made their skin break out in a rash. The RR stated there was tape on the resident's stomach this morning when they arrived, and they had to remove it. On 8/22/24 at 10:08 AM, the surveyor reviewed the medical record for Resident #68. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included Parkinson's disease; dementia; generalized anxiety disorder; failure to thrive (syndrome of weight loss, decreased appetite and nutrition); major depressive disorder, and bipolar. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/1/24, reflected the resident had a brief interview for mental status (BIMS) score of a 3 out of 15, which indicated a severely impaired cognition. A further review included the resident had a feeding tube (g-tube) which they received greater than 51% of their daily calories and over 501 milliliters (mL) of fluids via the g-tube. A review of the Medication Review Report (MRR) included a physician's order (PO) dated 3/15/24, to cleanse the g-tube with normal saline solution and cover with a four by four (4 x 4) drain sponge (gauze) daily. Do not use tape on skin. On 8/22/24 at 12:30 PM, the surveyor observed Resident #68 sitting in the dining room with the RR. At that time, the RR informed the surveyor that there was adhesive tape on the resident's abdomen, and they pulled up the resident's shirt to show the surveyor. The surveyor asked if they could go back to the resident's room to show the nurse, and the RR stated yes. On 8/22/24 at 12:35 PM, the surveyor asked the Unit Manager/Licensed Practical Nurse (UM/LPN #1) to accompany them to the Resident #68's room and look if the resident had adhesive tape on their abdomen. UM/LPN #1 with the resident's permission observed the resident's abdomen, and confirmed there was adhesive tape and removed it. The RR at that time stated that the Gastrointestinal (GI) Physician did not want adhesive tape on the resident's stomach because it caused a rash. The RR stated that the GI Physician instructed that the gauze should have been wrapped around the tube and not taped to the abdomen. On 8/22/24 at 12:45 PM, UM/LPN #1 provided the surveyor with the GI consultation dated 3/12/24, which she stated that the GI Physician only recommended limit use of tape with dressing and the GI Physician did not indicate no tape. The surveyor asked if the PO indicated do not tape, and UM/LPN #1 confirmed it did. The surveyor asked if the nurses were expected to follow the PO's as written, and UM/LPN #1 confirmed yes. On 8/22/24 at 1:03 PM, the surveyor interviewed Resident #68's nurse for the day, the Licensed Practical Nurse (LPN #2), who stated she was an Agency nurse, and it was her first day on the unit. LPN #2 stated when she arrived at the unit today, she was informed the resident's treatment was done, and she observed the dressing looked clean, so she did not touch it. LPN #2 stated she was unaware the dressing should not have adhesive tape until someone brought it to her attention when the RR informed them. On 8/22/24 at 1:15 PM, the surveyor continued to review the medical record. A review of the Progress Notes included a Nurse Practitioner (NP) note dated 3/15/24 at 1:00 PM, which the NP noted that the resident's skin at their g-tube site was red and irritated from the adhesive tape. The NP ordered to not use adhesive tape on the skin. On 8/22/24 at 1:52 PM, the surveyor interviewed the Acting DON who stated nurses were expected to carry out a physician's order as written. The Acting DON confirmed the nurse should not have used adhesive tape on the resident's g-tube site. A review of the facility's Administering Medications policy dated updated October 2023, included medications must be administer in accordance with orders, including the required timeframe .if a drug is withheld, refused, or given at another time other than the scheduled time, the individual administering the medication will document in medication administration record . 38079 4. A review of the facility provided, Policy for Emergent Infectious Diseases [EID] (COVID-19) Outbreak Plan V10 dated updated 1/1/24, included but was not limited to; Goal: to protect residents, families, and staff from .exposure to an emergent infectious disease while they are in our care center. 2. Local Threat: . d. staff will be educated on the exposure risks, symptoms, and prevention of the EID . 3. Suspected case in the care facility: g. implements the isolation protocol .please refer to (Isolation-Categories of Transmission-Based Precautions). A review of the facility provided policy, Isolation-Categories of Transmission-Based Precautions revised/reviewed 1/2024, included but was not limited to; Policy Interpretation and Implementation: 1. Transmission-based Precautions will be used whenever measure more stringent than Standard Precautions are needed to prevent or control the spread of infection. Contact Precautions: 6 Resident Transport b. If the resident is transported . to another facility, the Infection Preventionist (or designee) will notify the unit or facility of the type of precautions the resident is on and the resident's suspected or confirmed type of infection. The facility is also responsible for notifying transport staff of residents that require special care due to infectious conditions. Droplet Precautions: 5 Resident Transport c. If the resident is transported . to another facility, the Infection Preventionist (or designee) will notify the unit or facility of the type of precautions the resident is on and the resident's suspected or confirmed type of infection. The facility is also responsible for notifying transport staff of residents that require special care due to infectious conditions. On 8/26/24 at 10:38 AM, the Infection Preventionist/LPN (IP/LPN) reviewed the facility's Line Listing (LL) with the surveyor. The IP/LPN revealed that residents who were COVID-19 positive would be noted on the LL and that contact tracing would be performed to evaluate if additional residents, staff, or visitors may have been exposed to COVID-19. Upon reviewing the provided information, the surveyor noted that Resident #100 had tested positive for COVID-19 on 7/23/24, and was the only resident listed as having had gone to the hospital with the comments documented, not COVID related. A review of the electronic Progress Notes (PN) included the following: A PN dated 7/23/24 at 9:35 AM, documented that Resident #100 was threatening, shouting, and attempting to elope and was transported to [name redacted] hospital. On the same date at 5:30 PM, that the resident returned from the hospital and was COVID-19 positive. A PN dated 7/24/24 at 10:18 AM, documented that Resident #100 was uncooperative, using vulgar language and threatening staff. On the same date at 11:18 AM, the resident was transported to [name redacted] hospital for evaluation. The resident was transported by two transporters at 12:20 PM. Resident #100 was admitted to the hospital. The next PN in the medical record was dated 7/30/24 at 10:00 PM, when the resident was readmitted to the facility. There was no evidence in the PN's that the facility informed the medical transporters or receiving hospital that Resident #100 required transmission-based precautions for COVID-19. A review of the New Jersey Universal Transfer Form dated 7/24/24, item #12 isolation/precaution was left blank. Item #19 Attached Documents which included items such as physicians orders, was left blank. A review of Resident #100's medical record Admission Record printed 8/27/24, revealed the resident had diagnoses which included but were not limited to; depression, dementia, and psychosis. The list of diagnoses failed to include COVID-19 onset date of 7/23/24. A review of the most recent quarterly MDS dated [DATE], reflected the resident had a BIMS score of 5 out of 15, indicating Resident #100 had severe cognitively impairment. A review of the Order Summary Report revealed an order dated 7/23/24, that the resident was on contact and droplet precautions [ .] for diagnosis of COVID-19. A review of the ICCP included a focus area that the resident required isolation precautions specifically related to COVID-19 with interventions which included to educate staff, resident, family and visitors of COVID-19 signs and symptoms and precautions. On 8/26/24 at 11:13 AM, the surveyor interviewed the IP/LPN, who stated if a resident was going to the hospital, that the staff filled out the Universal Transfer Form and wrote isolation precautions on the form. The IP/LPN also stated that the staff called the hospital with a report, and they verbally informed the transport staff. The IP/LPN confirmed it was important to document in case the receiving staff did not get to the resident right away in the hospital. On 8/27/24 at 10:57 AM, the surveyor asked the IP/LPN and Acting DON in the presence of the survey team, about informing the transporters and receiving hospital regarding Resident #100 being COVID-19 positive. The Acting DON stated if it was not documented that it was reported to transport and the hospital staff that the resident was COVID-19 positive, it was not done. She further stated COVID-19 positive results should be documented on the New Jersey Universal Transfer Form to ensure whoever receives the resident was aware. The Acting DON stated that if the COVID-19 positive status was not conveyed, it could spread the infection. On 8/27/24 at 11:21 AM, the IP/LPN stated that the COVID-19 precautions were on the physician's orders, but she could not provide any documentation that transport or anyone at the receiving hospital was made aware that Resident #100 was COVID-19 positive. No additional information was provided. NJAC 8:39-11.2, 27.1, 29.2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication. This deficient practice was identified in 3 of 3 medication carts inspected, and was evidenced by the following: On 8/26/24 at 9:55 AM, the surveyor, in the presence of the Registered Nurse (RN), inspected the B-Wing nursing unit's Medication Cart #2 and observed two unidentifiable, loose medication pills of varying shapes, color, and size in the bottom of the drawer containing the medication blister packages. At that time, the RN confirmed that there should be no loose pills in the medication cart, and that the nurses assigned to the cart were responsible for maintaining the organization and cleanliness of the cart and its contents. On 8/26/24 at 10:37 AM, the surveyor, in the presence of the Unit Manager/Licensed Practical Nurse (UM/LPN), inspected the C-Wing nursing unit's Medication Cart #1 and observed nineteen unidentifiable, loose medication pills of various colors, shapes, and sizes in the bottom of the drawer containing the medication blister packages. At that time, the UM/LPN confirmed that there should never be any loose pills in the medication cart, and that the nurses assigned to the cart were responsible for maintaining the organization and cleanliness of the cart and its contents. On 8/26/24 at 11:11 AM, the surveyor, in the presence of the Licensed Vocational Nurse (LVN), inspected the A-Wing nursing unit's Medication Cart #1 and observed six unidentifiable, loose medication pills of various colors, shapes, and sizes in the bottom of the drawer containing the medication blister packages. At that time, the LVN confirmed that there should never be any loose pills in the medication cart, and that the nurses assigned to the cart were responsible for maintaining the organization and cleanliness of the cart and its contents. On 8/26/24 at 12:22 PM, the surveyor interviewed the Acting Director of Nursing (DON), who stated all medications should be stored in the packaging in which it was received, and that there should be no loose pills in the medication carts. A review of the facility's Medication Storage policy dated reviewed January 2024, included the facility shall store all medication and biologicals in a safe, secure, and orderly manner .medications and biologicals shall be stored in the packaging, containers, or other dispensing system in which they are received . NJAC 8:39-29.4

Complaint NJ #: 172074 Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to provide Speech Therapy services to a resident in a timely manner. This deficient practice was identified for 1 of 1 resident reviewed for rehabilitation (Resident #226), and was evidenced by the following: On 8/19/24 at 11:04 AM, during the initial tour of the facility, the surveyor observed Resident #226 in their room in bed. The surveyor asked the resident if they were receiving speech, physical, or occupational therapy and the resident stated not yet, but that was the plan. On 8/19/24 at 1:00 PM, the surveyor reviewed the medical record for Resident #226. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; hemiplegia (paralysis of one side of the body), cerebral vascular accident (damage to the brain from an interruption of blood), hypertension (high blood pressure), and gastrostomy tube (a feeding tube (FT) into the stomach for artificial feeding). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 5/7/24, reflected the resident had a brief interview for mental status (BIMS) score 7 out of 15, which indicated a severely impaired cognition. A further review revealed that the resident had upper and lower extremity impairment on one side, and they required maximum assistance for eating. A review of the Order Summary Report included the following physician's orders (PO) dated 7/27/24, for Occupational Therapy (OT), Speech Therapy (ST), and Physical Therapy (PT) evaluation and treatment as recommended. A further review included a PO dated 7/31/24, for aspiration precautions (practices that help prevent food, fluids, saliva, or foreign objects from entering a person's lungs) every shift. On 8/20/24 at 12:03 PM, the surveyor reviewed the therapy schedule from C-wing which included names and times of all therapies for the unit residents. Resident #226 was not on the therapy schedule. On 8/20/24 at 12:07 PM, the surveyor interviewed the Director of Rehabilitation (DPT), who stated she was a ST. The DPT stated that the resident did not receive physical therapy or occupational therapy yet because the family wanted to wait to get the resident a Botox injection. On 8/22/24 at 10:58 AM, the surveyor reviewed Resident #226's physician's orders which included the PO dated 7/27/24, for the ST evaluation. The surveyor asked the DPT why the resident did not receive the ordered ST evaluation, and the DPT responded that she needed to check if it was completed. On 8/22/24 at 11:03 AM, the DPT informed the surveyor that the ST evaluation was missed, and she would complete the evaluation on the resident at lunch today. The DPT could not speak to why the evaluation was not done at the time ordered, and the surveyor asked if the evaluation should have been a priority since the resident had oral feeds, a FT, and was on aspiration precautions and the DPT responded, yes. The surveyor asked the DPT what the facility's process was for receiving new therapy orders, and the DPT stated that the nurse informed her in morning meeting, and the nurse probably did not inform her of Resident #226's ST evaluation order. On 8/26/24 at 1:05 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Acting Director of Nursing (DON), in the presence of the survey team, their concern. The Acting DON acknowledged that the resident was received a ST evaluation after surveyor inquiry. A review of the facility's Tender Touch policy dated revised February 2020, included evaluations may be performed by licensed Physical, Occupational, and Speech therapists. Evaluations should be initiated within 24 hours of the order and completed within 48 hours as feasible . NJAC 8:39-37.1

Based on observations and interviews, it was determined that the facility failed to ensure that the resident call bell system functioned by: a.) ensuring call bell light illuminated outside of the resident's room when pushed; b.) call bell system volume was set to a level to be heard; and c.) the call bell system accurately identified the room in need of assistance. This deficient practice was identified for 3 of 10 call bell lights tested and was evidenced by the following: On 8/21/24 at 1:45 PM, the surveyor in the presence of the Regional Maintenance Director (RMD) observed that Resident Room A-5 (door) call bell light did not illuminate outside of the resident's room when tested by the RMD. The call bell system identified the room incorrectly as 0222, and there was no audible notification at the nurse's station call bell system. On 8/21/24 1:46 PM, the surveyor in the presence of the RMD observed that Resident Room A-5 (window) call bell did not illuminate outside of the resident's room and did not register a signal at the nurse's station call bell system when tested by the RMD. On 8/21/24 at 1:48 PM, the surveyor in the presence of the RMD, observed that Resident Room A-4 (door) call bell did not illuminate outside of the resident's room and there was no audible notification at the nurse's station call bell system when tested by the RMD. On 8/21/24 at 1:49 PM, the surveyor in the presence of the RMD, observed that Resident Room A-4 (window) call bell did not illuminate outside of the resident's room and there was no audible notification at the nurse's station call bell system when tested by the RMD. On 8/21/24 at 2:00 PM, the surveyor in the presence of the RMD, observed that Resident Room A-30 call bell did illuminate outside of the resident's room and was properly identified at the nurse's station call bell system when tested by the RMD but there was no audible notification. Interview at the time of the observations, revealed that the Licensed Nursing Home Administrator (LNHA) confirmed that there was no audible notification. Upon further investigation of the call bell system, the LNHA discovered that the audible notification volume was turned all the way down on the call bell system and proceeded to raise the volume so that audible notification could be heard. On 8/22/24 at 11:10 AM, the surveyor interviewed the facility's Resident Call Bell System Vendor (RCBSV), who stated that they were in the process of updating the call bell system on the computer. The RCBSV stated that the updates were to correct the room identification displayed at the nurse's station, and they would stay and verify that the system was working properly before they left. The LNHA was notified of the deficient practice at the Life Safety Code exit conference on 8/22/24. NJAC 8:39-31.2(e); 31.8(c)9

Complaint # : NJ 163368 Based on observation, interview, and record review, the facility failed to update a care plan of one Resident (R) 8) unable to reposition themself, of three residents reviewed for pressure injuries. This failure to relate information to staff has the potential to affect the healing process of a stage four pressure injury. Findings include: Review of a facility's Grievance Log provided by the facility, revealed on 04/06/23, a grievance filed by R8's guardian regarding the positioning of him in bed related to the presence of a stage four pressure injury on the right hip, which the nurse on duty claimed was on the left hip. Review of R8's Order Summary from the facility electronic medical record (EMR), Orders tab showed an admitted [DATE] with medical diagnoses that included cerebral palsy, adult failure to thrive, stage four pressure ulcer of the right hip, and pressure-induced deep tissue damage of the right hip. The Order Summary also showed an order for wound cleansing with half-strength Dakins solution, apply honey gel to the wound and cover with a super absorbent dressing daily. In response to the grievance, the facility held an in-service training for staff regarding wound care and positioning of residents with wounds. Observation of R8 on 04/26/23 at 5:20 PM showed he was positioned on his right side. The Director of Nursing (DON) confirmed R8's position and advised the Certified Nurse Aide, that came to room to assist R8 with his meal, the resident was not to be on his right side. Review of R8's Care Plan from the EMR Care Plan tab showed a care plan for right ankle wounds, that are documented in the EMR by the wound care physician as healed on 01/20/23, further review of the care plan revealed. Focus: Patient has an stage 4 wound to right hip. Date Initiated: 01/13/2023, Revision on: 04/24/2023. Goal: Patient's unstageable wound will show signs of healing by review date. Date Initiated: 01/13/2023. Revision on: 04/24/2023.Target Date: 04/28/2023. Interventions: Administer treatment to unstageable wound as ordered. Date Initiated: 01/13/2023. Air loss mattress -Date Initiated: 04/24/2023. Enhanced barrier precautions-Date Initiated: 04/25/2023. Wound consult with wound doctor-Date Initiated: 01/13/2023. Additionally, Focus: The resident has actual impairment to skin integrity of the right hip-Date Initiated: 01/13/2023-Revision on: 01/13/2023. Goal: I will not experience any additional skin breakdown or other complications. Date Initiated: 01/13/2023-Revision on: 04/24/2023-Target Date: 04/28/2023. Interventions: I will regain skin integrity; reddened or pressure areas will decrease in size. Date Initiated: 01/13/2023-Revision on: 04/24/2023-Target Date: 04/28/2023. Assist me with my general hygiene and comfort measures-Date Initiated: 01/13/2023. Follow facility protocols for treatment of injury-Date Initiated: 01/13/2023. Keep my linen dry, clean, and free of wrinkles-Date Initiated: 01/13/2023. Keep skin clean and dry. Use lotion on dry skin-Date Initiated: 01/13/2023, Revision on: 01/13/2023. While the care plan was updated on 04/24/23, there was nothing included regarding the positioning of residents. During interviews with Certified Nurse Aides (CNA's) regarding where information to care for a resident was located, it was discovered: 04/27/23 at 1:35 PM, CNA5 was asked about R8's positioning the evening before and responded, I was on A hall, I went to feed them. When asked where he would find the information to care for him, CNA5 stated, I don't know. The DON told me don't put him on that side because of the wound. If we don't know how to take care of them, we always ask the nurse. 04/27/23 at 4:10 PM, CNA1 stated, I ask the nurse if there is anything new, I am given information at report. 04/27/23 at 4:14 PM, in a joint interview with CNA3 and CNA4 responded: CNA3: The nurse gives you report. CNA4: If you don't know, you ask the nurse. When asked if you do not know a resident, if there was any information in their Point of Care charting system, CNA4 responded, No and CNA3 stated, If you don't know the patient the nurse will tell you, she will know. 04/27/23 at 4:45 PM, CNA2 responded, Before I care for a resident, especially if it is a new resident, I ask the nurse and receive information during report. In an interview on 04/27/23 at 4:17 PM, regarding where information to care for a resident was found, Licensed Practical Nurse (LPN) 3 responded, The chart and the report I get, the rounds on a patient, and I go through the resident chart to see. When asked what the care plan included, LPN3 stated, The care plan is to guide what the patient is at risk for. In an interview on 04/27/23 at 6:35 PM, the DON stated, an expectation the care plan would be updated for resident care. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, updated 10/2022, revealed: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 13. Assessments of residents are ongoing and care plans are revised as information about the residents [sic] and residents' conditions change. Review of the facility policy titled Pressure Ulcer/Injury Risk Assessment, updated 10/2019, showed: . 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. The [sic] b. effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate.

Complaint # : NJ 163368 Based on observation, interview, and record review, the facility failed to ensure the positioning of one Resident (R) 8) unable to reposition themself, of three current residents reviewed for pressure injuries, was conducive to the healing of a stage four pressure injury. This failure to relate ensure appropriate positioning has the potential to affect the healing process of a stage four pressure injury. Findings include: Review of a facility's Grievance log provided by the facility, dated 04/06/23 revealed R8's guardian filed a grievance regarding the positioning of him in bed related to the presence of a stage four pressure injury on the right hip. Review of R8's Order Summary from the facility electronic medical record(EMR), Orders tab showed an admitted [DATE] with medical diagnoses that included cerebral palsy, adult failure to thrive, stage four pressure ulcer of the right hip, and pressure-induced deep tissue damage of the right hip. The Order Summary also showed an order for wound cleansing with half-strength Dakins solution, apply honey gel to the wound and cover with a super absorbent dressing daily. In response to the grievance, the facility held an in-service training for staff regarding wound care and positioning of residents with wounds on 04/07/23. Observation of R8 on 04/26/23 at 5:20 PM showed he was positioned on his right side. The Director of Nursing (DON) confirmed R8's position and advised the Certified Nurse Aide that came to room to assist R8 with his meal the resident was not to be on his right side. During interviews with Certified Nurse Aides (CNA's) regarding where information to care for a resident was located, it was discovered: 04/27/23 at 1:35 PM, CNA5 was asked about R8's positioning the evening before and responded, I was on A hall, I went to feed them. When asked where he would find the information to care for him, CNA5 stated, I don't know. The DON told me don't put him on that side because of the wound. If we don't know how to take care of them, we always ask the nurse. 04/27/23 at 4:10 PM, CNA1 stated, I ask the nurse if there is anything new, I am given information at report. 04/27/23 at 4:14 PM, in a joint interview with CNA3 and CNA4 responded: CNA3: The nurse gives you report. CNA4: If you don't know, you ask the nurse. When asked if you do not know a resident if there was any information in their Point of Care charting system, CNA4 responded No and CNA3 stated, If you don't know the patient the nurse will tell you, she will know. 04/27/23 at 4:45 PM, CNA2 responded, Before I care for a resident, especially if it is a new resident, I ask the nurse and receive information during report. In an interview on 04/27/23 at 4:17 PM regarding where information to care for a resident was found, Licensed Practical Nurse (LPN) 3 responded, The chart and the report I get, the rounds on a patient and I go through the resident chart to see. When asked what the care plan included, LPN3 stated, The care plan is to guide what the patient is at risk for. In an interview on 04/27/23 at 6:35 PM, DON stated an expectation the staff would know how to position the resident off the hip with the pressure ulcer. Review of the facility policy titled Pressure Ulcer/Injury Risk Assessment, updated 10/2019, showed: .2. Risk factors that increase a resident's susceptibility to develop or to not heal PUiPIs include, but are not limited to: a. Under nutrition, malnutrition, and hydration deficits; b. Impaired/decreased mobility and decreased functional ability; .

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) routinely change the dressing surrounding a central venous catheter (a thin, flexible tube that is inserted into a vein, usually below the right collarbone and threaded into a larger vein above the right side of the heart), b.) obtain a Physician's Order (PO) to flush the Central Venous Catheter (CVC), and c.) develop a comprehensive care plan for the care of the CVC. This deficient practice was identified for one of one resident's reviewed, (Resident #14) for care related to a CVC. This deficient practice was evidenced by the following: On 11/28/22 at 12:39 PM, the surveyor observed Resident #14 sitting upright in bed, naked, with a sheet covering the resident's body. At that time, the surveyor observed that the resident had a CVC in his/her right upper chest. The surveyor further observed a clear plastic dressing surrounding the CVC. The edges of the clear, plastic dressing surrounding the CVC were observed to be peeling and curling up at the sides. The clear plastic dressing was further observed to be undated. The surveyor observed that the resident's CVC had a double lumen (a small, flexible, open tubing attached to the CVC that medication can be administered into) with two blue caps on them. The resident stated that he/she was readmitted from the hospital about three weeks ago and the staff working at the facility had only changed the dressing to the CVC once since his/her re-admission to the facility. The resident told the surveyor that facility staff had not been flushing his/her CVC with normal saline (a prescription solution used to flush the lines of the central venous catheter to maintain patency). On 11/30/22 at 11:36 AM, the surveyor observed the resident lying in bed naked with a sheet covering the resident's bare chest. The resident stated that the staff changed the dressing to the CVC yesterday (11/29/22). The surveyor observed that the clear, plastic dressing surrounding the CVC was curling up at the edges and undated. On 12/02/22 at 10:06 AM, the surveyor observed the resident sitting upright in bed scrolling through Face Book (FB) on his/her cell phone. The surveyor observed a clear, plastic dressing over the CVC on the resident's right upper chest. The dressing was dated 12/01/22. The surveyor reviewed the electronic medical record for Resident #14. A review of the resident's Admission Record reflected that the resident was admitted to the facility in the beginning of August 2022 and readmitted the second week of November 2022. A further review of Resident #14's Admission Record indicated that the resident had diagnoses which included but were not limited to lupus erythematosus (an inflammatory disease when the immune system attacks its own tissues), anemia (a condition where the blood does not have enough healthy red blood cells and leads to reduced blood flow to the body's organs), morbid obesity due to excess calories, antiphospholipid syndrome (a disorder in which the immune system mistakenly attacks normal proteins in the blood), and sickle-cell trait (an inherited group of disorders in which the red blood cells form a sickle shape which reduces blood supply to the spleen). A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 08/19/22, reflected that the resident had a Brief interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. A review of the resident's August 2022 Medication Administration Record (MAR) reflected a prn (as needed) PO dated 8/06/22, to change catheter site transparent dressing. A further review of the resident's August 2022 MAR did not reveal that the nurses had signed that they changed the resident's CVC dressing site as needed. The August 2022 MAR further reflected a PO dated 8/05/22, to change IV dressing per sterile technique every Monday during night shift. There were no signatures for the above PO on the August 2022 MAR. The August 2022 MAR indicated a PO dated 8/06/22, to flush each unused lumen with 10 millimeters (ml) of normal saline followed by 10 ml of heparin every 12 hours for patency. A review of the August 2022 MAR indicated that the nurses signed that they flushed the CVP at 0900 (9:00 AM) and 2100 (9:00 PM) on 08/06/22. A further review of the August 2022 revealed no further signatures for the above PO. A review of the August 2022 Treatment Administration Record (TAR) did not reveal a PO for the dressing change of the CVC or a PO to flush the CVC to maintain patency. A review of the resident's September 2022 MAR reflected a prn PO dated 9/04/22, to change catheter site transparent dressing. A further review of the resident's September 2022 MAR did not reveal that the nurses had signed that they changed the resident's CVC dressing site as needed. A continued review of the September 2022 MAR revealed a PO dated 9/14/22, to change CVC line per sterile technique every week and prn when it became wet or dislodged. The PO reflected to hold the CVC dressing change from 9/14/22 to 9/25/22. A further review of the September 2022 MAR reflected that the nursing performed the dressing change to the CVC site on Friday 9/16/22 and Friday 9/23/22. The September 2022 MAR indicated a PO dated 9/04/22, to flush each unused lumen with 10 millimeters (ml) of normal saline followed by 10 ml of heparin every 12 hours for patency. A review of the September 2022 MAR indicated that the nurses signed that they flushed the CVP at 0900 (9:00 AM) and 2100 (9:00 PM) on 09/04/22. A further review of the September 2022 revealed no further signatures for the above PO. A review of the September 2022 TAR did not reveal a PO for the dressing change of the CVC or a PO to flush the CVC to maintain patency. A review of the October 2022 MAR did not reveal a PO to change the CVC dressing. A review of the October 2022 MAR revealed a PO dated 10/11/22, to flush each unused lumen with 10 ml of normal saline followed by 10 ml of heparin every 12 hours for patency. A further review of the October 2022 MAR reflected that the nurses signed that they flushed the CVP at 0900 (9:00 AM) and 2100 (9:00 PM) from 10/11/22 through 10/19/22. The PO was put on hold on 10/20/22 and 10/21/22 then discontinued. A review of the October 2022 TAR did not reveal a PO for the dressing change of the CVC or a PO to flush the CVC to maintain patency. A review of the November 2022 MAR did not reveal a PO to change the CVC dressing. A further review of the November 2022 MAR did not reflect a PO to flush the unused lumen of the CVC to maintain patency. A review of the November 2022 TAR did not reveal a PO for the dressing change of the CVC or a PO to flush the CVC to maintain patency. A review of the December 2022 MAR revealed a PO dated 12/02/22, after surveyor inquiry to flush CVC with 20 ml of normal saline, followed by 5 ml of heparin every shift. A further review of the December 2022 MAR reflected a PO dated 12/02/22, after surveyor inquiry to change CVC with transparent dressing on admission, weekly, and as needed every Thursday night. A review of the December 2022 TAR did not reveal a PO for the dressing change of the CVC or a PO to flush the CVC to maintain patency. A review of the resident's comprehensive care plan did not reveal a focus area that the resident had a CVC or goals and interventions for the care of the CVC. On 12/02/22 at 11:27 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who told the surveyor that she was not the resident's regular assigned CNA, but she had taken care of the resident before and was assigned to care for the resident that day. The CNA stated that the resident was alert and oriented and had a central line in his/her right upper chest. The CNA further stated that she never performed care on the resident's CVC because that was the nurses responsibility. On 12/02/22 at 11:37 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that she regularly cared for Resident #14, the resident was alert and oriented and was able to make his/her needs known. The LPN told the surveyor that the resident had a CVC in his/her right upper chest and the dressing change for the CVC was not performed during her shift, but the resident was able to verbalize when he/she wanted the dressing to be changed. The LPN stated that the purpose of routinely changing the dressing to the CVC was to prevent an infection. The LPN further stated that the nursing staff flushed the CVC lumen (lines) with normal saline and the purpose of flushing the lines was to maintain patency. The surveyor asked the nurse how frequently the lumen to the CVC were flushed and the nurse stated that she was unsure, but it does get flushed. The LPN told the surveyor that if the dressing changed to the central line was being performed and the central line was being flushed, there should have been a PO to reflect the care. The LPN further stated that the purpose of the PO would be to inform the nurses of the frequency and accountability of the care. The LPN stated that if a resident had a CVC that would be something that would be care planned for and the unit managers were responsible for creating the care plans for the residents. On 12/02/22 at 11:57 AM, the surveyor reviewed the December 2022 MAR and December 2022 TAR in the presence of the resident's LPN and identified that there were no PO's to sign for changing the resident's CVC dressing or flushing the CVC. On 12/02/22 at 11:59 AM, the surveyor interviewed the resident's Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that she was new to the position and in training. The LPN/UM further stated that if a resident had a CVC there should be a PO to reflect the care of the CVC. The LPN/UM told the surveyor that the CVC dressing should have a PO to be changed weekly and as needed and the lines into the CVC should be flushed every shift. The LPN/UM further stated that the dressing change was important because the dressing acted as barrier to prevent infection and flushing the lumen maintained patency of the CVC. The LPN/UM stated that the resident's CVC should be care planned for. On 12/02/22 at 12:04 PM, the surveyor interviewed the Director of Nursing (DON) who stated if a resident had a CVC, the resident should have a PO for the CVC dressing to be changed weekly or as needed. The DON further stated that if the resident was not regularly receiving an Intravenous (IV) medication through the central line, the CVC should be flushed once a shift and the care of the CVC should be care planned for. A review of the facility's, Central Venous Catheter Dressing Changes Policy and Procedure reviewed 1/10/22, indicated that the purpose of changing a CVC was to prevent infections. The Facility's, Central venous Catheter Policy and Procedure further indicated that the documentation that was required to be in the resident's medical record included: the date and time the dressing was changed, the location and objective description of the insertion site, complications and interventions that were performed for the resident, and the signature and title of the person recording the information. The facility's Policy and Procedure did not specify how frequently the resident's CVC was to be changed. A review of the facility's, Central Venous and Midline Flushing policy and Procedure reviewed 1/10/22, indicated that the purpose of the procedure was to maintain the patency of the CVC. The facility's Central Venous and Midline Flushing policy and Procedure further indicated that when the CVC was flushed, The following information should be documented in the resident's medical record: 1. The date and time the medication was administered. 2. The amount of flush administered. 3. The route and rate of the medication administered. 4. The condition of the IV site before and after administration. 5. Notification of the physician, if there are any complications. 6. Resident response. 7. The signature and title of the person recording the data. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care was completed. This deficient practice was identified for 1 of 27 residents reviewed, (Resident #36) for accurate completion of a significant change MDS. The deficient practice was evidenced by the following: On 11/28/22 at 10:45 AM, the surveyor observed Resident #36 lying in bed. At that time, the surveyor attempted to interview the resident. The resident was unable to verbally respond, made eye contact with the surveyor, shook his/her head and smiled. The surveyor further observed that the resident's lips and gums were pink and moist. On 11/30/22 at 10:56 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that Resident #36 was discharged from hospice on 09/16/22. On 12/01/22 at 11:19 AM, the surveyor interviewed the Minimum Data Set/Registered Nurse (MDS/RN) in the presence of the Regional/Minimum Data Set/Registered Nurse (R/MDS/RN). The MDS/RN stated, The MDS hospice area documented as the patient being on hospice was an error. The surveyor reviewed the medical record for Resident #36. A review of the Admission Record, reflected that Resident #36, was admitted to the facility on [DATE] with a diagnosis which included but not limited to unspecified dementia with behavioral disturbances. A review of the residents annual MDS dated [DATE], reflected the Brief Interview for Mental Status score (BIMS) of 0 out of 15 which refelcted the resident had severely impaired cognition. A further review of the resident's MDS, Section - O - Special Treatments, Procedures, and Programs indicated that the resident was on hospice services. A review of the residents Significant Change MDS dated [DATE], revealed in Section - O - Special Treatments, Procedures, and Programs that the resident was receiving hospice services. A review of the Hospice Visit Note dated 9/16/22, provided by the Director of Nursing (DON) on 12/1/22 at 8:30 AM, revealed that Resident #36 was admitted to hospice services on 07/29/20 and discharged from hospice services on 09/16/22 A review of the CMS's RAI version 3.0 Manual for MDS revealed a provider should Code residents identified as being in a hospice program. NJAC 8:39-11.2

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) that two residents who had [DIAGNOSES REDACTED].) had a system was in place to prevent unqualified staff from feeding residents who were dependent on staff for feeding assistance. This deficient practice was identified for 2 of 5 Residents (Resident #18 and #19) reviewed that required feeding assistance. The facility's failure to ensure qualified staff fed residents who were at risk for aspiration resulted in an immediate jeopardy situation to the residents health and safety of residents who had difficulty swallowing and specific feeding strategies. According to a Speech Therapy Discharge Summary dated 11/9/2018, Resident #18 requires HTL (honey thick liquids) at this time due to diff (difficulty) with positioning. This resulted in an Immediate Jeopardy (IJ) situation that began on 3/27/19 at 1:07 p.m., during the lunch meal dining observation, and was corrected on 3/27/19 at 7:54 p.m., based on an acceptable removal plan that included; no staff member other than a nurse, Certified Nursing Assistant (CNA) or staff member who has completed the state approved paid feeding assistant program will feed a resident. The Plan of Correction (P[NAME]) was accepted by the survey team on 3/28/19 at 11:17 a.m., and verified throughout the remainder of the survey that it had been implemented by the facility. This deficient practice was evidenced by the following: 1. On 3/27/19 at 1:07 p.m., the surveyor observed a facility staff member standing between the residents and simultaneously them. The two residents were identified as Resident #18 and Resident #19. Resident #18 was observed in a Tilt in Place wheelchair ( a wheelchair that tilts on its frame designed for pressure relief and positioning) and was being fed a pureed diet with honey thick liquids. The second resident, Resident #19, was in a manual recliner chair and was also being fed a pureed diet with honey thick liquids. At 1:11 p.m., the surveyor interviewed the facility staff member feeding Resident #18 and Resident #19. The staff member identified herself as a Recreation Assistant (RA). The RA added that she routinely fed both residents breakfast and the lunch meal in the unit dining room. At 1:15 p.m., the surveyor observed the Unit Manager (UM) speaking with the RA. The Unit Manager informed the RA that she would feed Resident #19 their lunch meal, and that the RA should continue to feed Resident #18. The UM also directed the RA to sit while feeding the resident. At 1:36 p.m., the surveyor interviewed the RA about her training for feeding Residents. The RA stated that she had completed a training course with the Nurse Educator (NE), and that she routinely fed residents, especially during the lunch meal. The RA added, that she would look for signs of choking and would notify a nurse if there were any signs of choking. At 2:15 p.m., the surveyor interviewed the Speech Language Pathologist (SLP), as well as, the Director of Rehabilitation. The SLP stated that a referral had been sent by nursing in the fall of (YEAR) for an evaluation due to Resident #18's increased coughing during meals. Resident #18 received Speech Therapy Services for the period of 10/16/18 - 11/15/18 for Dysphagia (difficulty swallowing). The SLP added that Resident #18 required total assistance with meals. The SLP further stated, that if the resident did not open their mouth wide, had tongue thrusts and/or turned away, that with encouragement the resident could follow commands. At that same time, the Director of Rehabilitation stated that Resident #18 was in a specially designed Tilt-in-Place wheelchair (WC), and that it was the best WC for the resident. The Director of Rehabilitation stated that two rehabilitation screens were completed each year based on the requirement of the resident's medical insurance. The surveyor reviewed Resident #18's medical record, which revealed that the resident was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A review of the speech therapy discharge note dated 11/9/18, under discharge recommendations, read: No speech therapy services are recommended upon discharge. Under Summary of Care skilled services provided, the discharge note read: Swallow therapy for diet analysis, feeding strategies determination, and training in the appropriate safe swallow strategies to prevent aspiration and reflected Resident #18 requires HTL (honey thick liquids) at this time due to diff (difficulty) with positioning. In addition under Discharge recommendations Nursing to follow-up if Patient has improved positioning with new seating system. A review of Resident #18's medical record, revealed a Medical Department General Note written by the Nurse Practitioner on 2/15/19 at 14:23 (2:23 p.m.) that read: Monitor for symptoms aspiration-cough. A review of Resident #18's Nutritional Assessment by the SLP with an effective date of 1/4/19 written at 8:56 a.m. indicated under Swallowing, that nectar thickened fluids were downgraded to honey thick fluids and that the resident was tolerating the mechanically altered diet. A review of Resident #18's most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 1/3/19, Section B: (Hearing, Speech, and Vision) indicated no speech, rarely never understood and rarely/never understands. Section C (Cognitive Patterns) revealed that Resident #18 had memory problems with short and long term memory and that the resident was severely impaired in decision making. Under Sections G (Functional Status), the MDS revealed that Resident #18 was totally dependent (one person physical assist) with eating. Upon continued record review, the surveyor did not identify a care plan for aspiration precautions/risk. 2. On 3/27/19 at 2:22 p.m., the surveyor interviewed the SLP and Director of Rehabilitation about Resident #19. The Director of Rehabilitation informed the surveyor that Resident #19 was in a manual recliner chair. The SLP and the Director of Rehabilitation stated that a referral had been sent by nursing in the fall of (YEAR) because the staff had noticed an increase in coughing with meals. The SLP added that Resident #19 was on a pureed diet with honey thick liquids at that time. Resident #19 received speech therapy with dates of service from 11/27/18 - 12/19/18 for Dysphagia. The Speech Therapy Discharge Summary for Dysphagia dated 12/19/18 under recommendations read: No speech therapy services are recommended at this time. Under Summary of Care-skilled services provided, it read: Swallowing therapy improving tolerance of least restrictive diet level via determining appropriate feeding, safe swallowing strategies and training caregivers in their use. The surveyor then reviewed the medical record of Resident #19 which revealed an Admission Record that identified that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record, revealed a Care Plan Meeting dated 10/9/18 at 12:00 noon that read: Resident continues a pureed diet with honey thick liquids and was fed by staff. Additionally, there was a verbal order dated 11/9/18 for speech/swallow evaluation regarding cough after eating and drinking, rule out aspiration and under plan of care to include swallowing management. Surveyor review of Resident #19's most recent MDS revealed under Section B: (Hearing, Speech, and Vision), that the resident had no speech, was rarely/never understood and rarely/never understands. Under Section C: (Cognitive Patterns), it revealed that Resident #19 had memory problems with both short and long term memory, and was severely impaired in decision making. Under Section G: (Functional Status), it revealed that Resident #19 was total dependence of one person physical assist with eating. The surveyor reviewed a care plan created on 12/7/09, with the Focus identified as: (Resident #19) is at risk for aspiration related to impaired swallowing Dx (Diagnosis) of Dysphagia. At 2:24 p.m., the surveyor interviewed the facility Nurse Educator (NE) who confirmed that the facility did not participate in the state approved feeding assistance program. The NE added, that no one would feed a resident until they received education. At that time, the NE revealed that the facility had not participated in the Feeding Assistant Program. The NE stated that the RA and Assistant Director of Recreation would no longer be feeding any residents. The NE confirmed that there were no other staff members that fed residents. During the Brief Entrance Conference with the Administrator and Director of Nursing (DON) on 3/27/19 at 9:22 a.m., the surveyor was informed that the facility did not have Paid Feeding Assistants. On 3/27/19 at 2:40 p.m., the surveyor interviewed the Assistant Director of Rehabilitation who confirmed that she would routinely feed three residents on the A-Wing dining Room. The three residents on the A-Wing were added to that Resident Sample and were investigated. No adverse effects were noted. The surveyors did not observe unqualified staff feeding residents for the remainder of the survey. The Administrator was made aware of the IJ situation on 3/27/19 at 7:30 p.m. The IJ was corrected and verified on 3/27/19 at 7:54 p.m., based on an acceptable removal plan that no staff member other than a nurse, CNA or staff member (who had completed the state approved paid feeding assistant program) would feed residents. On 3/28/19 at 11:17 a.m., the survey team accepted the P[NAME] and continued to verify the P[NAME]. N.J.A.C 8:39 - 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to adequately monitor the skin, specifically the fingers, of Resident #24, who had a known behavior of biting the fingers. The resident developed a severe infection of the finger followed by an amputation of the tip of the right, third finger. Resident #24 was 1 of 1 residents reviewed for non-pressure related skin wounds. This deficient practice was evidenced by the following: On 2/22/18 at 10:00 AM, the surveyor observed Resident #24 in the resident's room seated in a wheel chair. After the surveyor said hello to the resident, the resident said to the surveyor, Look, I had my finger amputated. The resident showed the surveyor the right middle finger with the tip absent. The skin was healed. On 2/23/18 at 11:58 AM, a family member of Resident # 24 approached the surveyor and reported that the resident had to have the tip of their finger amputated (middle right) following a severe infection turning the tip of the finger black. The family member showed the surveyor a picture on his/her cellular phone. The family member said the picture of Resident #24's finger was taken the day the facility discovered the wound. The picture shown to the surveyor was that of a swollen middle finger with a black tip. The family member further stated that no one at the facility noticed the wound on the resident's finger until the resident went to the hospital and it had to be amputated. The daughter said this occurred the previous month (January). The family member also said that he/she did not see the resident every day, but did see the resident a couple of times a week. The family member stated on the last visit he/she did not notice any wound on the resident's hands, but did say the resident had a habit of hiding their hands. On 02/28/18 at 09:21 AM, the surveyor asked the resident what happened to the finger and why did it have to be amputated? The resident replied, I was biting it. On 2/28/18 at 9:40 AM, the surveyor reviewed the resident's medical record which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that a skin check was performed on 1/15/18 at 11:49 AM by a Licensed Practical Nurse (LPN) . The skin check did not document any wound to the finger. The surveyor then reviewed a progress note written by the Nurse Practitioner (NP) dated 1/18/18 at 12:24 PM. The progress note read: Seen for report of R (right) middle finger swelling/redness. Member is awake, alert, oriented x 2 w/ (with) forgetfulness. (The resident) reports that (the resident) hit (their) finger 2 weeks ago. Finger is red/swollen, nail appears to be missing w/ dry blood under the skin. Nsg staff reports that the member bites (their) fingers/nails and hides it. The NP ordered an x-ray of the finger and oral antibiotics. The surveyor reviewed a progress note written by the resident's attending physician dated 1/18/18, the time was not included but according to the Director of Nursing (DON) the resident was seen by the attending physician after the resident was seen by the NP. The progress note read: Asked to see the resident for R (right) middle finger [MEDICAL CONDITION]. and also Right middle finger without any nail with [MEDICAL CONDITION] and necrotic area. and Right middle finger .[MEDICAL CONDITION] with some necrotic tissue, rule out osteo[DIAGNOSES REDACTED] will send to hospital for evaluation. A Nurses Note dated 1/18/18 at 6:15 PM read: Left for the hospital at 6:15 pm. There was a signed physician's orders [REDACTED]. The surveyor reviewed the Hospital record which included a History and Physical by a physician dated 1/19/18 at 1:31 PM that read : Nursing Home resident who presented in the emergency room with swelling, tenderness, and black discoloration of (the) right third fingertip. According to the patient, (they) had a problem with the wheelchair 3-4 weeks ago when the finger was stuck on the wheels. It went on eventually and according to the patient's family when they visited (the resident) yesterday they noticed this black discoloration, swelling and redness of (the) finger. It further read: The swelling is decreased since yesterday when started giving (the resident) the IV antibiotics. The surveyor reviewed the hospital surgeons note dictated at 1/21/18 at 2:21 PM which read: The patient is a (age) year old (gender) with a history of diabetes mellitus, hypertension, [MEDICAL CONDITIONS], and [MEDICAL CONDITION], who is admitted to the hospital from nursing facility for a severe infection of (the) right middle finger that appears to have been progressing over a number of weeks. On clinical examination, the patient has evidence of gangrene at the tip of the right middle finger with erosion of the portion of the underlying distal phalynx (the bone of the finger furthest from the body) consistent with osteo[DIAGNOSES REDACTED] and [MEDICAL CONDITION] of the remaining portion of the right middle finger. The surveyor reviewed a second hospital surgeon's note dated 1/20/18 at 6:15 PM which read: I (discussed with) patient, son, and daughter re R (right) middle finger infection (gangrene/osteo[DIAGNOSES REDACTED]) and management options (including) amputation of distal R middle (3rd) finger and shorten post op course of (antibiotics) vs. extended 6 week course of IV antibiotics. Given severity and chronicity of infection, it appears unlikely that antibiotics alone will resolve it. Amputation distal R (right) middle finger recommended. The surveyor reviewed the Behavior Monitoring and Interventions sheet for the months of (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). Under the behavior symptom of Biting Fingers there were no incidents of this type of behavior listed until 1/25/18, the day after the resident was readmitted to the facility following the finger amputation. The surveyor reviewed the residents care plan titled, Resident exhibits behavior: biting finger nails with revision dates of 10/31/16, 6/28/16, and 2/26/16. Interventions listed were; allow resident time to vent feelings/needs, approach resident in a calm friendly manor, divert resident by giving alternative objects or activity, document interventions and resident response, encourage resident to attend activities of choice and adjust time spent to resident's tolerance and attention span, med options consult and follow up, provide 1 : 1 interaction and support as needed. On 3/2/18 at 10:00 AM, the surveyor spoke with the Licensed Practical Nurse (LPN) that was assigned to the resident that day and also for the month of (MONTH) (YEAR) at the time of the amputation. The surveyor interviewed the LPN concerning what happened with the resident's finger. The LPN stated, (The resident) has been hiding the finger. Even when the aides wash (the resident) they give (the resident) the washcloth and (he/she) can do it (themselves). The surveyor asked the LPN about the day the wound was discovered on the finger. The LPN stated, The aide told me (the resident) got tiny blood on the shirt then I went to see where the blood was coming from. The resident was touching (their) stomach and I saw (their) hand. (The resident) didn't want us to look at it. I called the Unit Manager (UM). The UM called the Nurse Practitioner (NP) and she came and checked it. The Director of Nursing (DON) checked it too. The resident was upset because (he/she) didn't want us to see it. The surveyor asked the LPN about skin checks. The LPN stated, We did weekly skin checks. The surveyor asked if skin checks included the fingers. The LPN stated, Yes, but we didn't do skin check that day maybe 5 days before. The surveyor asked the LPN about the cognitive status of the resident and the LPN said the resident was alert and oriented with confusion and made false statements. On 3/2/18 at 10:20 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who took care of the resident for the month of (MONTH) (YEAR) and asked about the wound that was found on the resident's finger in January. The CNA stated, I don't know about (the resident's) finger because when I wash (the resident) I give (the resident) the wash cloth and (the resident) do it (themselves). (The resident) is showered on 3-11. I don't know anything about (the resident's) finger. On 3/5/18 at 11:00 AM, the surveyor asked the Assistant Director of Nursing (ADON) for the investigation regarding the injury to the finger. The ADON said they did not do an investigation because it was an infection. The surveyor asked how the resident got the infection. The ADON stated, The (resident) was biting on (the resident's) finger. Later that day, the ADON further explained that facility staff discussed the matter and concluded that because there had been no accident that caused an injury to that finger the resident must have been biting it which led to the infection and injury to the finger. The ADON confirmed that the resident was being monitored for biting the fingers. The surveyor asked if the staff looked for the behavior alone or evidence of the behavior. The ADON said they look for the behavior. On 3/5/18 at 1:45 PM the surveyor asked the DON about the day the wound was discovered on the right middle finger of Resident #24. The DON stated, I looked at it myself with the Nurse Practitioner. She ordered (oral) antibiotics. I saw it and said oh no, she's got a systemic infection. It was swollen and red. (The attending physician) came and saw it. When he saw it, he sent her right out (to the ER). On 3/6/18 at 9:00 AM, the surveyor interviewed for a second time the LPN that was assigned to Resident # 24 during the month of (MONTH) when the wound on the finger was discovered. The surveyor asked what she remembered about the day the finger tip wound was discovered. The LPN stated, (The resident) hides (his/her) fingers. (They) get so mad when you ask (him/her) to see (their) fingers. Like the day we saw the wound (he/she) was so mad that everyone was coming and asking to see (his/her) fingers. The surveyor asked the LPN if she remembered the day of the 1/15/18 skin check. The LPN stated, No, I don't remember what day it was but I know I looked at (his/her) fingers and it was not there. There was nothing on (his/her) fingers. The surveyor asked the LPN where the skin checks were done. The LPN stated, In (his/her) room, in the (wheel) chair. The surveyor asked the LPN how she would check the whole body if the resident was in a wheel chair. The LPN stated, I make (him/her) stand up. The surveyor asked the LPN if she did the skin checks alone or with someone else. The LPN said, By myself. Following the interview with the LPN, the surveyor reviewed the most recent Minimum Data Set assessment ((MDS) dated [DATE]. Under section G0300 Balance During Transitions and Walking, for moving from seated to standing position the code was 2 which meant not steady, only able to stabilize with staff assistance. Under section G0400 for Functional Limitation in Range of Motion the code was 2 which meant impairment on both sides of lower extremities (hip, knee, ankle, foot). The surveyor also reviewed the Activities of Daily Living (ADL) Record for the month of (MONTH) (YEAR). In the section for Transfer-How resident moves between surfaces including to or from: bed, chair, wheelchair, standing position under resident performance the resident was coded either an E which meant Extensive Assistance-Resident involved in activity, staff provided weight bearing support (I had to push/pull/lift) or the resident was coded a D which meant Total Dependence-Full staff performance during entire shift (I did everything for the resident who could not help). Under Staff Support Provided Codes the resident was either coded a 1 which meant One Person Physical Assist or a 2 which meant Two or More Person Physical Assist. For the day shift on 1/15/18, the day of the last documented skin check before the finger wound was discovered, the codes for the resident was D/1, which meant Resident #24 was totally dependant and required 1 person physical assistance. When questioned by the surveyor on 3/6/18 the LPN said she did the skin check for the resident alone in the residents room while the resident was fully dressed and in a wheel chair. On 3/6/18 at 9:10 AM, the surveyor interviewed the Unit Manager (UM) and asked if the staff monitor the behavior of finger biting for Resident #24 or do they look for evidence of the behavior. The UM stated, Nurse is supposed to look at patient's behavior on a daily basis and psych will follow up. The Aide will report to the nurse if she see something happen with skin integrity. The UM told the surveyor that the day the finger wound was discovered, on 1/18/18, it was the first day she came back from vacation and the Certified Nursing Assistant (CNA) that saw the finger and told the nurse was not the resident's regular CNA. On 3/6/18 at 9:20 AM, the surveyor spoke with the resident's attending physician. The physician stated, When I saw it, it was necrotic, very swollen with redness. Like an infection of finger nail, so massively swollen. That was the first time someone called me and the first time I saw it. I can see it could have been progressing 2-3 days. If it was not that swollen and they could have gotten it early maybe not as advanced but it seemed to progress very quickly. I can't tell you what the nurses role was. I can just tell you what I saw. On 3/6/18 at 11:00 AM, the surveyor reviewed the facility's Policy and Procedure titled, Skin Integrity Management under Policy it read; The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. On 3/6/18 at 11:10 AM, the surveyor reviewed the facility's Policy and Procedure titled, Behaviors: Management of Symptoms under Policy it read; Based on the comprehensive assessment, staff must ensure that a patient: Who displays or is diagnosed with [REDACTED]. N.J.A.C. 8:39-27.1 (a)

A.) Based on observation, interview, and documentation review on 12/12/16, in the presence of facility management, it was determined that the facility failed to use portable electric heaters in a safe manner in accordance with manufacturer's safety standards to prevent fire. This deficient practice had posed a serious and immediate threat to the safety of residents, staff, and visitors when an electric space heater was left on unattended in an unsupervised area and in close proximity to resident living areas. The heat emanating from the space heater registered 262 degrees Fahrenheit (F.) This deficient practice was evidenced by the following: On 12/12/16, at 12:10 p.m., during the Life Safety Code tour, the surveyor observed that there was a electric heater in-use on an open bookshelf in the Medical Director's (MD) office. The heater was on at the highest heat setting and oscillating side to side. When the heater oscillated to the right, the imitation wood support for the bookshelf partially obstructed the front of the heater leaving the support warm to the surveyor's touch. The surveyor observed that there were combustible items within 3-feet of the heat source, including paper products on the shelf below the heater. The room was not occupied at this time by staff. The non-fire rated door to the room was closed but not locked from access and opened to the resident sleeping unit. Resident room B-28 was located on the opposite wall of the room. At 12:15 p.m., the Director of Maintenance (DM) tested the temperature of the heating element of the unit with the facility's non-contact infrared thermometer. The temperature measured 262 degrees F. at the heating element. The facility's DM then removed the device from the room. In an interview, at the time, the facility's DM stated that the device belonged to the MD and that the heater was not permitted in the building. The DM also stated that the MD was notified that this heater was not permitted in the past. In another interview, at the time, the facility's Corporate Property Manager (CPM) stated that he had conducted a Life Safety Code audit of the facility 2 months ago where this heater was identified and reported to the Administrator (LNHA). The CPM stated that the heater was observed in the room on the shelf but was not plugged in at the time. The surveyor reviewed the facility's Electrical Safety and Work Related Practices policy that reflected residents were not permitted to use electric space heaters. However, the policy did not address the use of these heaters by staff or contracted services. No other policies could be provided by the facility with regards to electric space heaters. A review of the manufacturer's safety instructions revealed the following Warnings that were not followed by the facility: 1. Keep combustible material, such as furniture, pillows, bedding, papers, cloths, and curtains at least 3-feet (0.9 m) from all sides of the heater. 2. Place the product upright on a flat, level, stable, heat-resistant surface, and then plug the Power Cord into a standard 120-volt electrical outlet. 3. Insure that no objects will be near the heater during the full range of oscillation when using this function. 4. Always unplug the product when it will be left unattended or not in use. At 1:05 p.m., the Administrator (LNHA) was notified that the deficient practice had posed a serious and immediate threat to the resident's, staff's, and visitor's safety. In an interview at 1:37 p.m., the facility's MD stated that he was told to use the heater by the maintenance department because the office heat was not working and was 20 to 30 degrees colder in the office than in the facility. The MD also stated that he would put the heater on whenever he first came in to the office as he had that day. The Immediate Jeopardy was corrected at 1:43 p.m. on 12/12/16 with an acceptable plan of correction (POC) and verification of the elements of the POC by the survey team. The survey team continued the verification of in-services related to the POC throughout the survey. The elements of the POC included the following: 1. The space heater was immediately removed by the Maintenance Director.2. All offices and resident areas of the facility were checked by the maintenance personnel for the use of space heaters. No other space heaters were found. 3. Maintenance personnel will install a permanent heat source in medical director's office. 4. All staff, including the medical director, will be educated not to use space heaters in the facility and notify maintenance of any heat related concerns. 5. All offices and resident areas will be checked by maintenance personnel daily for two weeks. Then weekly until March 31, 2017 for the use of space heaters. If any space heaters are found, they will be immediately removed and staff educated as appropriate. 6. Results of the audits will be submitted to QAPI (Quality Assurance Program) monthly. The deficiency continued at a lower scope and severity of D based on the evidence in Part B. B.) Based on observation, interview, and record review, it was determined that the facility failed to maintain proper electrical connections with medical equipment for Resident # 13 and Resident # 18, who were of 2 of 21 residents reviewed. The deficient practice was evidenced by the following: 1. On 12/13/16 at 10:50 a.m. the surveyor observed a power strip in use on the top shelf of a 3 shelf cart next to the bed of Resident # 13. At 12 p.m. the surveyor asked the Unit Manager (UM) what was plugged into the power strip. The UM checked the power strip and called out the items one by one, the suction machine, the bed, the ventilator/respirator, the nebulizer, the oxygen concentrator, the fan, and the power strip is plugged into the red wall outlet. The UM acknowledged that she was aware of the regulation prohibiting medical equipment from being plugged into a power strip. 2. At 12:10 p.m. the surveyor checked the room of Resident # 18. There was a 3 pronged extension cord plugged into the wall outlet. The surveyor verified with the UM what was plugged into the 3 pronged extension cord. The UM called out the items one by one, the suction machine, the nebulizer, the aerosol mister. At 12:40 p.m. the surveyor spoke with the Director of Maintenance (DM) who stated that he was unaware of the electrical configuration in those rooms and he would be addressing it with the nursing department. In the meantime, the wall outlets were powered by emergency generator in the event of a loss of power. The surveyor reviewed the facility's policy and procedure titled Electrical Safety and Work Related Practices. The section titled Equipment Restrictions: 4.3 read Do not use multiple plug adapters or power strips to compensate for an inadequate number of permanent electrical outlets. NJAC 8:39-31.7 (g) NJAC 8:39-31.1(c), 31.2(e)