Every finding on record at Complete Care at Summit Ridge

Complaint #: 2661084Based on interviews, medical record review, and review of other pertinent facility documentation on 11/17/2025 and 11/20/2025, it was determined that the facility failed to report a verbal abuse allegation that a resident's representative (RR) reported to the facility's staff and to the Department of Health (DOH) for 1 of 3 residents reviewed for abuse. The deficient practice was identified for 1 of 3 residents reviewed (Resident #3) and was evidenced by the following:According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: paraplegia (type of paralysis that affects the lower half of the body), spinal stenosis (when the space inside the backbone is too small and puts pressure on the spinal cord), and diabetes. According to the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/24/2025, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact.A review of the facility's document titled Summary of Investigation dated 11/10/2025 revealed that the RR reported to the facility that a nurse told Resident #3 to shut up. On 11/17/2025 at 12:40 PM, the surveyor conducted a phone interview with RR who stated that Resident #3 had told her that a staff member had told the resident to shut up. The RR further stated that the resident was unsure of the staff member's name. The RR stated she reported what was told to her to the facility's Social Worker (SW) but could not remember the date she reported the incident to the SW.On 11/20/2025 at 10:29 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the allegation was not reported to the DOH because the resident said there was no verbal abuse that had occurred. The LNHA stated that the resident denied the abuse allegation and was cognitively intact. LNHA further stated that staff were interviewed and nothing was able to be proven. The LNHA further stated that she would call the DOH about the alleged abuse. There was not evidence that facility fully investigated the allegation of verbal abuse or called the abuse to the DOH.A review of the facility's policy titled Abuse, Neglect, and Exploitation with a revised date of 5/1/2025 revealed under VII. Reporting/Response, 1. Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.NJAC 8:39-9.4

Complaint: 2661084Based on interviews, medical record review, and review of other pertinent facility documents on 11/17/2025 and 11/20/2025, it was determined that the facility failed to provide documented evidence that care was provided to a resident who required maximal assistance for toileting hygiene. This deficient practice occurred for 1 of 3 residents (Resident #3) reviewed.The deficient practice was evidenced by the following:According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: paraplegia (type of paralysis that affects the lower half of the body), spinal stenosis (when the space inside the backbone is too small and puts pressure on the spinal cord), and diabetes. According to the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/24/2025, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed that the resident needed substantial and maximal assistance with toileting hygiene and was frequently incontinent of bowel and bladder.A review of the facility's grievance forms dated 11/10/2025 revealed the following: Resident #3 reported they had concerns in the timeliness of having incontinence care completed on 11/2/2025 and 11/9/2025.A review of Resident #3's Documentation Survey Report, a form utilized for documentation of Activity of Daily Living (ADL) care by the Certified Nursing Assistants (CNAs) for November 2025, revealed NA on the following dates for toileting hygiene: 11/2/2025 on day shift (7-3) and evening shift (3-11)11/9/2025 on day shift (7-3) and evening shift (3-11)A review of Resident #3's Progress Notes (PNs) for November 2025, did not reveal that incontinence care was provided on the aforementioned dates. On 11/17/2025 at 9:45 AM, the surveyor conducted an interview with Resident #3. Resident #3 stated that there was one time when they sat in their feces. The resident was unable to tell the surveyor the date or time and no additional information. On 11/18/2025 at 9:54 AM, the surveyor conducted a telephone interview with Social Worker #2 (SW#2) who stated that Resident #3 and their representative complained within the last two weeks about the resident not being provided with incontinent care prior to eating.On 11/20/2025 at 9:45 AM, the surveyor conducted an interview with the Infection Preventionist (IP) and asked about NA. IP stated that she believed NA meant it was non-applicable. She further stated she did not know why it was documented unless the resident was out of the building which would be documented in the chart as part of the facility. The IP further stated she would not be able to speak on whether Resident #3's care was provided on 11/2/2025. The IP stated the unit managers and supervisors were responsible for checking the ADL documentation for completeness not the codes documented. The IP further stated it was important to document ADLs every shift to ensure care was given. On 11/20/2025 at 9:48 AM, the surveyor conducted an interview with Certified Nursing Assistant #1 (CNA #1) who confirmed that Resident #3 was incontinent. She stated that she provided total assistance for Resident #3 in addition to ADL care. CNA #1 stated she documents NA in the ADL documentation sheet if the resident did not have a bowel movement under the toileting and hygiene section. A review of the facility's policy titled Charting and Documentation with an updated date of 1/2022 revealed under Policy Interpretation and Implementation, 2. The following information is to be documented in the resident medical record: c: Treatments or services provided. The documentation of NA in the facility's Documentation Survey Report indicates not attempted . NJAC 8:39-27.1 (a)

Complaint #: 2661084Based on interviews, medical record review, and review of other pertinent facility documents on 11/17/2025 and 11/20/2025, it was determined that the facility failed provide evidence that a physician's order for wound care was carried out and documented for two days to treat a facility acquired pressure injury in accordance with professional standards. This deficient practice occurred for 1 of 3 residents reviewed for wound. The deficient practice was evidenced by the following:According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: paraplegia (type of paralysis that affects the lower half of the body), spinal stenosis (when the space inside the backbone is too small and puts pressure on the spinal cord), and diabetes. According to the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/24/2025, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact.A review of the facility's document titled Skin Injury dated 11/4/2025, revealed that Resident #3 was noted with an opening on their sacrum during care. A review of Resident #3's Progress Notes (PNs) dated 11/4/2025 revealed the following written by Licensed Practical Nurse (LPN #1): Cleanse with NS [normal saline], medi honey apply and cover. MD [Medical doctor] and family member made aware.A review of Resident #3's wound assessment report with date of service of 11/5/2025 revealed the following:Measurements: Length: 2.7 centimeters (cm)Width: 1.00 cmDepth: 0.10 cm. Observations: Location: coccyxEtiology: pressure ulcer/injuryStage/severity: stage 2acquired in house: yes Treatment: Dressing change frequency: BID (twice per day), and PRN (as needed)Clean wound with: cleanse with normal salinePrimary treatment: medical grade honey Other dressings: bordered foamA review of Resident #3's Order Summary Report (OSR) and Treatment Administration Record (TAR) revealed no evidence of physician's orders and no evidence the wound care to the resident's sacrum was provided on 11/4/2025 and 11/5/2025. A further review of Resident #3's OSR with an order date of 11/6/2025, revealed the following physician's order: Medi honey Wound/Burn Dressing External Gel. Apply to coccyx topically every day and evening shift for wound care. Clean with NS [normal saline], apply honey, cover with bordered form gauze. A review of Resident #3's TAR dated 11/6/2025 revealed the aforementioned order for wound care. On 11/17//2025 at 1:52PM, the surveyor conducted an interview with the Assistant Director of Nursing (ADON) who stated that if a wound was discovered, the nurse should call the doctor for treatment orders and put the orders in the computer. The ADON stated he did not see a wound care order for Resident #3's sacrum on 11/4/2025 and 11/5/2025. The ADON further stated that a wound care order should have been initiated on 11/4/2025. The ADON confirmed that Resident #3's wound care orders were initiated on 11/6/2025. The DON stated it was important to get treatment orders as soon as possible and put them into the computer so the wound would not get worse. On 11/20/2025 at 11:23 AM, the surveyor conducted an interview with LPN #1 who stated the Certified Nursing Assistant (CNA) made her aware of Resident #3's sacrum wound but was unable to recall the exact date. She stated that she and the supervisor wrote an incident report and that she notified the doctor. LPN #1 stated she was unsure of which doctor she notified. LPN #1 further stated if she wrote the note for 11/4/2025, it meant she got the order for the wound treatment on the same day. LPN #1 stated that when she got an order from the doctor, she would be responsible for putting it in the computer. LPN #1 stated she did not know why Resident #3's wound order was not put in the computer until 11/6/2025. A review of the facility's policy titled Wound Treatment Management with an implemented date of 6/1/2025 revealed under Policy Explanation and Compliance Guidelines, 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record.A review of the facility's policy titled Charting and Documentation with an updated date of 1/2022 revealed under Policy Interpretation and Implementation, 2. The following information is to be documented in the resident medical record: c. Treatments or services performed. 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided.NJAC 8:39-27.1 (a)

Based on observation, interview, and record review it was determined that the facility failed to maintain the dignity of 2 unsampled residents during the lunchtime meal in the main dining room and 1 sampled resident (#53) during a wound treatment observation. The deficient practice was evidenced by the following. 1. The surveyor observed the lunchtime meal in the main dining room on 05/22/25 at 12:23 PM. The surveyor observed as a Certified Nursing Assistant (CNA) placed a disposable clothing protector on a cognitively impaired resident. The CNA did not explain the procedure of placing the clothing protector prior to attempting to fit it over the resident's head. The clothing protector had a opening where it would be fitted over the resident's head. The opening was too small for the resident's head and got stuck with the clothing protector covering the resident's head and face. The resident became startled and tried to push the protector away from their head. The CNA was able to rip the clothing protector's opening so that it eventually fit over the resident's head. The CNA approached another cognitively impaired resident and repeated the same sequence of attempting to fit the clothing protector over the resident's head. The resident had the same startle reflex when the clothing protector became stuck over the resident's head and face. The CNA told the surveyor the clothing protectors usually have ties and not a pre-cut opening. The surveyor discussed the dignity concern with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) on 5/22/25 at 1:30 pm. The LNHA and DON examined a sample of the clothing protector and confirmed the opening was very small. 2. The surveyor observed the Licensed Practical Nurse (LPN) perform a pressure ulcer treatment to Resident #53 on 5/21/25 at 1:15 PM. When the LPN completed applying medication to the wound, she applied a cover dressing. The LPN wrote her initials and the date directly on the dressing while it was on the resident. The surveyor spoke with the LPN on 5/21/25 at 2:20 PM. The surveyor discussed the observation of the LPN writing directly on the cover dressing after it had been applied to the resident. The LPN replied she should have initialed and dated the dressing before applying it to the resident as it was a dignity issue. The LPN stated that she usually writes on the dressing before she applies it to the resident. On 5/23/25 at 2:11 PM, the surveyor discussed the above observations and concerns with the LNHA, DON , and Regional RN. The Regional RN confirmed that the dressing should have been initialed and dated prior to applying it to the resident. NJAC 8:39-4.1(a)12

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident. This deficient practice was identified for 1 of 29 residents reviewed for accommodation of needs (Resident #57), and was evidenced by the following: On 5/22/25 at 12:37 PM, the surveyor observed Resident # 57 seated in a wheelchair with his/her overbed table and lunch tray positioned in front of them. The surveyor observed that the resident's call bell (a bell used to summon staff for assistance) was in the middle of the bed not within the resident's reach. The surveyor reviewed the medical record for Resident #57. A review of the admission Record reflected that Resident #57 was admitted to the facility with diagnoses that included but were not limited to; Diabetes Mellitus, Schizophrenia and Leukocytosis. A review of Resident #57's Annual Minimum Data Set (MDS), an assessment tool dated 3/18/25 revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated moderate cognitive impairment. Section GG indicated Resident #57 required staff assistance for activities of daily living and transfers. A review of Resident #57's Individualized Comprehensive Care Plan (CP) initiated on 3/21/23 reflected a focus area: Resident is at moderate risk for falls related to gait and balance problems with interventions that included but were not limited to; be sure the call light is within reach and encourage the resident to use it for assistance as needed. On 5/22/25 at 12:41 PM, the surveyor showed the Registered Nurse (RN) assigned to Resident #57's care the call bell. The RN acknowledged that the call bell was not within the resident's reach. The RN stated that the resident required staff assistance with wheelchair mobility and transfers and that the Certified Nursing Assistant (CNA) who set the resident up should have put the call bell within the resident's reach. On 5/22/25 at 12:51 PM, during an interview with the surveyor, the CNA assigned to Resident #57's care stated that she had set the resident up for lunch. The CNA confirmed that the resident was unable to propel themselves in the wheelchair. The CNA acknowledged that she should have placed the call bell within the resident's reach. A review of the facility's Call Bell policy, undated reflected .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside .staff will ensure the call light is within reach of resident . On 5/23/25 at 2:11 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing and Regional Registered Nurse. NJAC 8:39- 27.1(a); 31.8 (c)(9)

Based on observation and interview, it was determined that the facility failed to post the prior year's State of New Jersey (State) inspection results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following. The surveyor conducted a group meeting on 5/22/25 at 10:30 AM, with 5 alert and oriented residents chosen by the facility. Five of 5 residents stated they did not know where to find the State inspection results. On 5/23/25 at 12:20 PM, the surveyor looked for the most recent State inspection results on the A and B Nursing Units and was unable to locate them. On 5/23/25 at 12:30PM, during an interview with the surveyor, the Director of Nursing (DON) stated that the results of the last survey were in a binder on the shelf by the receptionist. The surveyor observed the binder on the shelf behind the kiosk, not at wheelchair level and not easily accessible to residents. On 5/23/25 at 12:35 PM, the regional Registered Nurse (RRN) acknowledged that the binder should be kept in an area that is accessible to residents and that the residents should be able to access the book without asking. On 5/23/25 at 2:11 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, DON and RRN. NJAC 8:39-9.4(b)(c)

3. The surveyor observed Resident #38 awake in bed on 5/20/25 at 10:25 AM. The resident appeared to be confused and was unable to answer many of the surveyor's questions. The room contained 4 occupied resident beds. The surveyor greeted each of the residents and each appeared to be confused. The entire room lacked any type of decorations, personal items, bedspreads or other homelike effects. The surveyor discussed the undignified condition of the room with the LNHA and DON on 5/22/25 at 1:30 PM. No further information was provided by the facility. NJAC 8:39-4.1(a)11, 31.4 (a), (b), (c), (f) Based on observation and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 4 of 29 residents; (2 unsampled residents) and (Resident #60 and #38) reviewed. The deficient practice was evidenced by the following: 1. On 5/20/25 at 1:05 PM, the surveyor observed in an Unsampled Resident's room (Room A21), the privacy curtain was soiled with a white substance on several areas of the curtain. On 5/20/25 at 1:15 PM, the surveyor observed in an Unsampled Resident's room (Room A28), the privacy curtain was soiled with a white substance on several areas of the curtain. The surveyor observed on the wall by the headboards brown material splattered across the entire wall, ceiling tiles buckled and displaced, chipped paint on the wall by the window, and the radiator in the bathroom was rusted and soiled. On 5/23/25 at 12:15 PM, the surveyor interviewed the Regional Housekeeper (RHK), who confirmed that the privacy curtains were soiled and that the HK on the unit should be monitoring the curtains for cleanliness to provide the residents with a clean homelike environment. The RHK stated that the privacy curtains should be cleaned monthly and when needed. The RHK further confirmed that the wall in A28 should have been cleaned and the radiator in the bathroom should have been cleaned, repaired or replaced. On 5/23/25 at 2:11 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing (DON), and Regional Registered Nurse who confirmed that the resident rooms should be cleaned to provide a clean homelike environment. 2. On 5/20/25 at 10:03 AM, during the initial tour of Resident #60's room , the surveyor observed the top dresser drawer was opened and was hanging on the opened second drawer. The third drawer handle was broken and was affixed to the drawer by one screw as opposed to two. At that time, Resident #60 stated that the drawers were in the same condition from the time of their admission. A review of the work order log from January 2025 to May 2025 did not reflect a work order for Resident #60's dresser drawer. On 5/23/25 at 1:50 PM, during a tour with the surveyor, the Director of Maintenance (DOM) stated that the furniture, lighting and bedding for the C-wing where Resident #60 resided was checked two weeks ago. The surveyor and the DOM looked at Resident #60's dresser drawer together, the DOM began to repair the dresser drawer. At that time, the DOM stated that dresser drawer should have been functional and in good working order. At that time, the DOM stated that each area had a maintenance book where any staff who observed a broken equipment or furniture could report/write a request for repair.

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 1 of 4 Residents (Resident # 20), reviewed for respiratory therapy. 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 5/20/25 at 10:50 AM, the surveyor observed Resident #20 seated in a chair in their room with Oxygen (O2) delivered via a nasal cannula (NC) tubing, undated and attached to the O2 Concentrator at 2.5 liters per minute (LPM). The resident did not respond to the surveyor's greeting. On 5/21/25 at 12:00 PM, the surveyor observed Resident #20 seated in a chair in their room with O2 delivered via NC tubing, dated 5/20/25 attached to the O2 Concentrator at 2.5 LPM. The surveyor reviewed the medical record for Resident #20. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breath) and Alzheimer's Disease. A review of the current Order Summary Report revealed an active physician's order for Oxygen at 3 LPM via NC every shift with a start date 5/11/25. A review of Resident #20's Annual Minimum Data Set (MDS), an assessment tool dated 4/15/25, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident had a severe cognitive impairment. The MDS further revealed that Resident #20 received Respiratory treatments which included oxygen therapy. A review of Resident #20's Individualized Care Plan had a focus that indicated the resident had oxygen therapy related to acute respiratory failure with hypoxia initiated 4/11/25 with interventions that included but were not limited to; Oxygen settings: Humidified Oxygen via NC at 3 LPM continuously. On 5/21/25 at 12:05 PM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM), confirmed that the O2 gauge should have been set to infuse at 3 LPM. At that time the RN/UM increased the flow to 3 LPM. On 5/21/25 at 1:00 PM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) confirmed that she had not checked to ensure the O2 gauge was set to infuse at 3 LPM per the physician's order. The LPN stated she was not sure why the rate was at 2.5 LPM. On 5/23/25 at 2:11 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing and Regional Registered Nurse. NJAC 8:39-27.1 (a)

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) accurate administration of medications for Resident #70, b.) documentation of the removal of controlled dangerous substance (narcotic; with high potential for drug diversion) medication from inventory, maintained accountability, for accurate reconciliation of Resident #343, #132, #131, and #129's narcotic medications, identified during the medication storage inspection of 1 of 3 medication carts, c.) maintenance of the record keeping of the DEA Form-222 that ensured accurate ordering and receiving, narcotic inventory and reconciliation of controlled dangerous substance (narcotics medications, with high potential for abuse and are tracked with detail) identified in 1 of 14 forms reviewed and, d.) accurate receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 form) were completed with sufficient detail to enable accurate reconciliation identified in 1 or 14 forms reviewed and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 5/22/25 at 9:37 AM, the surveyor observed the Registered Nurse (RN) who prepared 7 medications for Resident #80 that included a physician's order (PO) for enteric coated (EC) delayed release (DR) 81 milligram (mg) of Aspirin (commonly used for pain, fever, inflammation and prevention of blood clots) to be given 1 tablet by mouth one time a day for prophylaxis. The surveyor observed the RN place two (2) tablets of 81 mg chewable Aspirin, in a medication cup for administration to Resident #80. At 9:41 AM, the RN stated she was ready to administer the medication to Resident #80, locked her cart and entered the Resident's doorway. At 9:42 AM, the surveyor asked to speak with the RN outside of Resident #80's room. At 9:43 AM, the surveyor and the RN reviewed the electronic Medication Administration Record (eMAR) and the prepared medications. At that time, the RN stated that she made an error in dispensing two (2) of the chewable Aspirins for administration since the order was for one (1) tablet. The RN also acknowledged that she incorrectly prepared the chewable aspirin [immediate release] and should have prepared the physician ordered, EC DR Aspirin from the stock bottle opposed to the PO of one (1) tablet. 2. On 5/22/25 at 11:56 AM, the surveyor and Licensed Practical Nurse (LPN) who was assigned to B- unit, began the narcotic medication inspection. The shift-to-shift accountability log was signed that day, and the LPN stated that there were no errors identified during the shift change. At that time, the LPN and the surveyor observed Resident # 343's Individual Patient's Controlled Substance Administration Record (IPCSAR; declining inventory sheet used to track removal of a controlled drug from inventory) for Oxycodone Immediate Release 5 milligram (IR, mg) that showed a documentation that a pill was destroyed without the date and the reason for disposition. At that time, the LPN acknowledged the date, and the reason should have been documented. Further observation of the narcotic medication revealed the following: -Resident #132's bingo card (a multi-dose card containing individually packaged medications) contained 9 tablets of the Oxycodone IR 5 mg. The IPCSAR reflected a quantity of 10 tablets. Additionally, on May 21 at 12:13 AM, and 9:00 AM, four tablets of the Oxycodone were removed from the inventory and the nurse who removed the Oxycodone had not signed the IPCSAR. -Resident #131's plastic bag contained three (3) packets of the Buprenorphine/Naloxone Sublingual Film .The IPSCAR reflected a quantity of 4 films. -Resident #129's bingo card contained 19 tablets of Methadone 10 mg. The IPCSAR reflected a quantity of 20 tablets. -Resident #129's bingo card contained 13 tablets of Clonazepam. The IPCSAR reflected quantity of 14 tablets. On 5/22/25 at 12:20 PM, during an interview with the surveyor, LPN #2 stated she administered the medications to the residents, and should have signed when it was poured from the bingo card. 3. On 5/22/25 at 11:14 AM, the surveyor and the Regional Corporate Nurse (RCN#1) reviewed 14 of the facility provided DEA Form-222 forms together. During the accountability review Order Form 23047619 was missing. The surveyor discussed the concern with the RCN #1. 4. On 5/22/25 at 12:49 PM, the surveyor and the RCN continued to review facility's DEA Form-222 together. Order Form Number (OFM) 230347814 reflected that the facility did not complete Part 5; the number of packages received and the date the medication was received were left blank. At that time, the surveyor discussed the concern with RCN #1 regarding the failure to ensure accurate reconciliation of the narcotics inventory. On 5/23/25 at 2:15 PM in the presence of the survey team, Regional Corporate Nurse (RCN #1) , RCN#2, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concern regarding the RN who prepared the incorrect quantity and dosage form of medication for Resident #80, the failure to maintain accountability for accurate reconciliation of Resident # 343, #132, #131, and #129 narcotic medications, failure to maintain a system of record keeping of the DEA Form-222, the failure to comply with the required receiving procedures for narcotics to ensure accurate reconciliation of narcotic inventory. At that time, RNC#1 acknowledged the medication pass error, and the DON stated that the nurses should have ensured the right dose and right drug was administered. RNC #1 acknowledged that the 222- forms should have been signed immediately after removal, and disposals should have a date, time and reason. A review of the facility provided policy, Medication Administration dated 1/1/20, included under explanation and compliance guidelines was to ensure that that six rights of medication administration were followed: right resident, right drug, right dosage . A review of the undated, facility provided policy for Controlled Dangerous Substances (CDS) included that the facility will properly distribute, maintain, and dispense controlled substances that are stored within the backup and emergency kit. All CDS are dispensed and handled in accordance with State and Federal guidelines. No further information was provided. NJAC 8:39-29.2(d), 29.7(c)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide a sanitary environment that helped prevent the development and transmission of communicable diseases and infections. This was identified for 3 of 29 residents (Resident #20, #53 and #57) reviewed for infection control. The deficient practice was evidenced by the following: 1. a. On 5/20/2025 at 11:10 AM, the surveyor observed Resident #53 in their bed. The surveyor observed an oxygen concentrator (a device that enriches air with oxygen by removing nitrogen) in the room with a humidifier bottle (a plastic bottle that infuses the normal flow of oxygen with water droplets) dated 10/25/24. The oxygen concentrator was not in use. The surveyor reviewed the medical record for Resident #53. A review of the admission record reflected Resident #53 was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's Disease, Diabetes Mellitus and Prostate Cancer. A review of the quarterly Minimum Data Set (MDS) an assessment tool, reflected Resident #53's Cognitive skills for Daily Decision Making were severely impaired. Section M assessed that Resident #53 had one stage 4 (full thickness tissue loss with exposed bone, tendon or muscle). A review of the current Order Summary Report (OSR) had an active physician's order (PO)with a start date 3/18/25 to apply oxygen per nasal cannula/mask at 2 liters per (LPM) minute as needed for Shortness of Breath (SOB). A review of Resident #53's Care Plan (CP) had a Focus area: The resident is on oxygen therapy when needed for periods of SOB with interventions that included but were not limited to; Administer oxygen via NC @ 3 LPM for O2 saturation below 93% in room air. On 5/21/25 at 12:45 PM, the surveyor showed the Licensed Practical Nurse (LPN) the humidifier bottle dated 10/25/24. The LPN stated that she should have checked the date on the humidifier bottle during her morning rounds but did not. On 5/21/25 at 1:05 PM, the Registered Nurse/Unit Manager (RN/UM) confirmed that the humidifier bottle should have been discarded and the bottle should be changed weekly per the facility policy. b. On 5/20/25 at 11:10 AM, the surveyor observed a sign outside of Resident #53's room that indicated the resident was on Enhanced Barrier Precautions (EBP); (an infection control practice designed to reduce the transmission of multidrug-resistant organisms in nursing homes). The surveyor observed Resident #53 was in bed on a specialty mattress. A review of Resident #53's current OSR revealed an active PO; to maintain EBP; an active PO with a start date 2/12/25 to; Cleanse sacrum area with Normal Saline every day and evening shift for wound healing; Apply Collagen Silver Alginate Pack to base of wound, and cover with a bordered gauze. On 5/21/25 at 1:15 PM, the surveyor observed the Licensed Practical Nurse (LPN) perform a pressure ulcer treatment to Resident #53's sacral wound. The LPN did not disinfect the overbed table before she placed the supplies on top of it. The LPN completed the treatment according to the physician's orders. The LPN informed the surveyor that she was done with the wound treatment and left the resident's room without disinfecting the overbed table that was used during the wound treatment. The surveyor spoke with the LPN on 5/21/25 at 2:20 PM. The surveyor discussed the observation of the LPN not disinfecting the overbed table before and after the treatment. The LPN confirmed she should have cleaned the table before she put the supplies on it and should have disinfected the table after the treatment was completed. A review of the Facility's Wound Care policy updated 5/2023 included .Clean overbed table with alcohol .return overbed table to its proper position. 2. On 5/20/25 at 11:08 AM, the surveyor observed Resident #57 in bed with two Intravenous (IV) antibiotic medication bags of Piperacillin Sod-Tazobactam (sterile bags that contained liquid antibiotic medication that had been administered) hanging on the IV pump (a device used to deliver fluids and medications directly into the bloodstream). The IV was not running and was not connected to the resident. One bag was not labeled with the date, time or initials of the nurse who administered the medication; and one bag was dated 5/20/25; no time or initials. The surveyor reviewed the medical record for Resident #57. A review of the admission Record reflected that Resident #57 was admitted to the facility with diagnoses that included but were not limited to; Diabetes Mellitus, Schizophrenia and Leukocytosis (elevated white blood cells.) A review of Resident #57's current OSR reflected an active PO with an order date 5/16/25; Piperacillin Sodium-Tazobactam IV Solution reconstituted use 3.375 gram intravenously every 8 hours for Leukocytosis. A review of Resident #57's Annual MDS dated [DATE] revealed Resident #57 had a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. Section GG indicated Resident #57 required staff assistance for activities of daily living and transfers. A review of Resident #57's CP initiated on 5/21/25 included a focus area: Resident is on antibiotics for leukocytosis with interventions that included but were not limited to; ensure regular monitoring of white blood cells and administering antibiotics as prescribed. On 5/22/25 at 12:41 PM, during an interview with the surveyor, the Registered Nurse assigned to Resident #57 stated that all IV bags should be labeled by the nurse administering the medication with the date, time and initials. A review of the facility's Intravenous Therapy policy dated 4/1/24 reflected .IV tubing is changed every 96 hours or sooner if contamination is suspected or integrity of system is compromised .All IV tubing is to be labeled with date, time and initials. 3. On 5/20/25 at 10:50 AM, the surveyor observed Resident #20 seated in a chair in their room with Oxygen delivered via a NC tubing, undated and attached to the O2 concentrator at 2.5 LPM. On 5/20/25 at 11:50 AM, the surveyor observed Resident #20 with a portable oxygen tank on the back of their wheelchair and a NC tubing hanging on the back of the chair undated and not contained in a bag. On 5/21/25 at 12:00 PM, the surveyor observed a portable oxygen tank on the back of the Resident's wheelchair with a NC tubing hanging on the back of the chair undated and not contained in a bag. The surveyor reviewed the medical record for Resident #20. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breath) and Alzheimer's Disease. A review of the current OSR revealed an active PO for Oxygen at 3 LPM via NC every shift with a start date 5/11/25; an active PO to change oxygen tubing and date weekly every night shift on Thursday with a start date 3/12/24. A review of Resident #20's Annual MDS dated [DATE], revealed Resident #20 had a BIMS score of 0 out of 15, which indicated the resident had a severe cognitive impairment. The MDS further revealed that Resident #20 received Respiratory treatments which included oxygen therapy. A review of Resident #20's CP included a focus that indicated the resident had oxygen therapy related to acute respiratory failure with hypoxia initiated 4/11/25 with interventions that included but were not limited to; Oxygen settings: Humidified Oxygen via NC at 3 LPM continuously. On 5/21/25 at 12:05 PM, the surveyor showed the Registered Nurse/Unit Manager (RN/UM) the NC tubing. The RN/UM confirmed that the tubing should have been dated and stored in a plastic bag when not in use. On 5/23/25 at 2:11 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing, and Regional Registered Nurse. N.J.A.C. 8:39 - 19.4 (a)

Based on observation, interview and record review it was determined that the facility failed to a.) maintain a Packaged Terminal Air Conditioner and Heating Unit (PTAC) in safe and optimal condition in an unsampled resident's room (Room A 21-2), b.) failed to ensure that the grab bar was securely affixed to the bathroom wall next to the toilet in Resident #20's room (Room A28-2) and, c.) failed to maintain the heat register unit in Resident #57's room (Room A20-1). This deficient practice was evidenced by the following: On 5/20/25 from 1:05 PM-1:30 PM, the surveyor toured the A Nursing Unit and observed the following: -The PTAC unit in room [ROOM NUMBER]-2 had broken and missing vents. -The grab bar in the bathroom in room [ROOM NUMBER] was loose and affixed to a broken tile and there were also several missing tiles. -The base board heat register in room [ROOM NUMBER] was pulled out of the wall and was on the floor in the bathroom with exposed pipes, which were not in working order. On 5/23/25 at 12:20 PM, during an interview with the surveyor, the Director of Maintenance (DOM) confirmed that he did not always inspect the bathrooms in the resident rooms during his morning rounds and stated that he should have. The DOM stated that he did not check the maintenance log on 5/20/25 and therefore was not aware that the heat register in Room A 20 needed to be repaired. The DOM further stated that it wasn't until the Certified Nursing Assistant told him about the broken heater on 5/21/25, that he became aware of the concern and fixed it that day. The DOM confirmed that he should check the maintenance log twice daily and that the staff should record maintenance concerns in the maintenance log. A review of the Hybrid maintenance Work Order Log dated 4/9/25-5/20/25 did not include work orders for Rooms A21 or A28. The report included a work order dated 5/20/25, that the bathroom heater in room A20, was broken; came out. On 5/23/25 at 2:11 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing, and Regional Registered Nurse. NJAC 8:39 - 31.2(e)

45449 Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a) dispensed and administered controlled substance (narcotic) medication was accurately accounted for (Resident #2, #12, #31, #78, and #120), b) discontinued medications were removed from active inventory (Resident #122 and #46), which was identified separately in two (2) of six (6) medication carts, c) medications were not pre-poured for more than one medication pass, medications were secured within the medication cart (Resident #78 and #12), d) medications were destroyed after resident refusal (Resident #12) e) accurate accounting of Resident #12's dispensed Tramadol (medication used for pain; a controlled substance tracked for substance abuse), which was identified in one (1) of four (4) nurses observed during medication administration f) expired narcotic medications were removed from the electronic back-up machine, identified for one (1) of one (1) of the electronic emergency backup machine observed during medication storage inspection. The deficient practice was evidence by the following: 1) On 3/16/23 at 10:39 AM, the surveyor and the Licensed Practical Nurse/Unit Manager#1 (LPN/UM #1) began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box), located in the low side of unit C. On 3/16/23 at 10:44 AM, in the presence of the LPN/UM #1, the surveyor observed Resident #2's Oxycodone/Acetaminophen (controlled pain medication) 5/325 milligram (mg) bingo card (a multidose card containing individually packaged medications) that contained 29 tablets. A review of the Individual Patient Controlled Substance Administration Record (declining inventory log) for Resident #2's Oxycodone/ Acetaminophen 5/325 mg indicated a count of 30 tablets and was not signed dispensed on 3/16/23. At that time, LPN/UM #1 informed the surveyor that the declining inventory log must be signed once a medication was dispensed from the bingo card. At that time, in the presence of the surveyor and LPN/UM#1, the Registered Nurse#1 (RN #1) assigned to the low side medication cart C stated he administered the Oxycodone/ Acetaminophen 5/325 mg to Resident #2 on that day. RN #1 stated he should have signed the declining inventory log immediately after he dispensed the medication. At that time, the LPN/UM #1 stated she would provide an in-service (education) to RN #1 and inform the Director of Nursing (DON) about the discrepancy on the accuracy of the inventory against the declining inventory log. The surveyor reviewed the medical records for Resident #2. The resident's electronic Medication Administration Record (eMAR) for Resident #2 reflected a signed administration of Oxycodone/Acetaminophen 5/325 mg on 3/16/23. On 3/16/23 at 10:53 AM, in the presence of the LPN/UM #1, the surveyor observed Resident #12's Tramadol 50 mg bingo card was missing. A review of the declining inventory log for Resident #12's Tramadol 50 mg indicated a count of one tablet and was last signed dispensed on 3/15/23 at 10:00 AM. The surveyor reviewed the medical records for Resident #12. The resident's eMAR for Resident #12 reflected a signed administration of Tramadol 50 mg on 3/16/23. On 3/16/23 at 10:57 AM, in the presence of the LPN/UM #1, the surveyor observed Resident #31's Lacosamide (used to prevent and control seizures) 200 mg bingo card that contained 11 tablets. A review of the declining inventory log for Resident #31's Lacosamide 200 mg indicated a count of 12 tablets and was last signed dispensed on 3/15/23 at 18:10. The surveyor reviewed the medical records for Resident #31. The resident's eMAR for Resident #31 reflected a signed administration of Lacosamide 200 mg on 3/16/23. On 3/16/23 at 11:02 AM, in the presence of the LPN/UM #1, the surveyor observed Resident #78's Diazepam (used to treat anxiety, muscle spasms, and seizures) 5 (five) mg bingo card that contained 26 tablets. A review of the declining inventory log for Resident #78's Diazepam 5 (five) mg indicated a count of 27 tablets and was last signed dispensed on 3/15/23 at 18:00. The surveyor reviewed the medical records for Resident #78. The resident's eMAR for Resident #31 reflected a signed administration of Diazepam 5 (five) mg on 3/16/23. On 3/16/23 at 11:04 AM, in the presence of the LPN/UM #1, the surveyor observed Resident #120's Tramadol 50 mg bingo card that contained 19 tablets. A review of the declining inventory log for Resident #120's Tramadol 50 mg indicated a count of 20 tablets and was last dispensed on 3/15/23 at 10:26 PM. The surveyor reviewed the medical records for Resident #120. The resident's eMAR for Resident #120 reflected a signed administration of Tramadol 50 mg on 3/16/23. On 3/16/23 at 11:34 AM, during an interview with the surveyor the LPN/UM #1 stated all narcotic medications should have been signed immediately once dispensed and removed from the narcotic box. On 3/16/23 at 11:39 AM, during an interview with the surveyor, RN #1 stated he signed the administration on the eMAR. He also stated he had not signed the declining inventory logs because his shift has not ended that day. RN #1 confirmed that he should have signed the declining inventory log immediately after dispensing the narcotic medications to the residents. On 3/16/23 at 11:43 AM, the LPN/UM #1 stated she would provide an in-service to the nurses. The LPN/UM #1 stated it was important to ensure the inventory count was correct and to ensure the medication was in fact dispensed and administered to the corresponding resident; that's our policy. 2) On 3/16/23 at 01:10 PM, the surveyor and the LPN began non-narcotic inspection of the medication cart located in the high side of unit C. At that time, the surveyor observed two (2) plastic ampules of Ipratropium-Albuterol (DuoNeb) 0.5-2.5 mg/3 milliliter (ml) with a handwritten open date of 01/13/23. The box was labeled by the provider pharmacy for Resident #122. The LPN informed the surveyor that she had not dispensed or administered the Ipratropium-Albuterol (medication comes as a nebulizer help lungs to breathe) 0.5-2.5 mg/3ml to the resident during her shift and it must have been discontinued. The surveyor reviewed the medical records for Resident #122. A review of the Order Audit Report ([NAME]) for Resident #120 reflected the Ipratropium-Albuterol 0.5-2.5 mg/3ml was ordered on 7/05/22 and was discontinued on 9/22/22. At that time, the surveyor observed a box of Ipratropium-Albuterol (DuoNeb) 0.5-2.5 mg/3 ml labeled by the provider pharmacy dated 9/13/22, for Resident #46. The LPN informed the surveyor that she had not dispensed or administered the Ipratropium-Albuterol 0.5-2.5 mg/3ml to the resident during her shift and it must have been discontinued. The surveyor reviewed the medical records for Resident #46. A review of the [NAME] for Resident #46 reflected the Ipratropium-Albuterol 0.5-2.5 mg/3ml was ordered on 9/10/21 and was discontinued on 3/10/23. On 3/16/23 at 01:15 PM, during an interview with the surveyor the LPN/UM #1 stated the 11 to 7 shift nurse was supposed to check the cart for expired and discontinued medications. They will inform us nurses on the 7 to 3 shift for follow up. On 3/16/23 at 01:16 PM, LPN/UM #1 stated there was a log for accountability but could not locate the corresponding accountability log at that time. The surveyor requested for LPN/UM #1 to provide further information as soon as she was able to locate the log. No further information was provided. On 3/16/23 at 01:20 PM, LPN/UM #1 stated she would remove the discontinued medications, separated from the active inventory and place with the other expired and discontinued medications in a locked medication room. 3) On 3/20/23 at 10:00 AM, on the C wing, the surveyor arrived and observed RN #2 attending to Resident #47 who was facing the side of the medication cart. The surveyor observed RN #2 administer medications to Resident #47 who left after medication administration. At that time, the surveyor observed pills in a medication cup. There were no markings on the medication cup to identify the intended resident. At that time, RN #2 stated the medications were already prepared (pre-poured) for Resident #78 prior to the arrival of Resident #13. RN #2 stated, Resident #13 arrived, requested for his medications and she proceeded to prepare and administer Resident #13's medications. At that time, the surveyor observed RN #2 crush Resident #78's pre poured medications, leave the medication cart and enter Resident #78's room with the crushed medications in hand. On 3/20/23 at 10:09 AM, the surveyor walked over to the other side of the same medication cart and observed an unlabeled packet that contained crushed medication(s) on top of the medication cart. On 3/20/23 at 10:13 AM, RN#2 returned to the medication cart after exiting Resident #78's room. RN#2 confirmed with the surveyor that the unlabeled packet contained crushed medications and that it was prepared for Resident #12. At that time, RN#2 stated she was an agency nurse, it was her first day, and she was not aware of the facility policy regarding unlabeled, unattended medications on her medication cart. 4) On 3/20/23 at 10:14 AM, in the presence of the surveyors, RN #2 stated she prepared Resident #12's medication but the resident was asleep. At that time, RN #2 stated she should not have left the unlabeled crushed medications on the cart because someone could have eaten it, pocketed it, or taken it physically and orally. RN #2 stated ingestion of unprescribed medications could result in unwanted adverse effects such as anaphylactic reaction (medical emergency and a life-threatening hypersensitivity reaction), hypotension (low blood pressure) and/or gastrointestinal issues (any condition that occurs from the mouth to the anus). On 3/20/23 at 10:20 AM, during an interview with the surveyors, RN #2 stated she should have disposed the unlabeled packet of medications for Resident #12 as soon as she received the refusal. RN #2 stated the packet contained the following: -Diltiazem (Cardizem; a medication used to lower blood pressure) -Zinc (supplement) -Hydralazine (a medication used to lower blood pressure) -Tramadol (a medication used for pain; a narcotic medication tracked for substance abuse). At that time, RN #2 informed the surveyors that she kept the unlabeled crushed medications in a packet on the cart because it contained Tramadol. At that time, RN #2 stated she was unsure of the policy regarding the disposal of Tramadol. On 3/20/23 at 10:26 AM, RN#2 left with the unlabeled packet of medications to speak with LPN/UM #1. On 3/20/23 at 10:28 AM, RN #2 and LPN/UM #1 returned to the medication cart. In the presence of the surveyors and LPN/UM #1, RN #2 stated yes, I did leave the crushed medications on the cart. 5) At that time, in the presence of LPN/UM #2 and RN #1, the surveyors observed the Resident #12's Tramadol 50 mg bingo card that contained eight tablets. A review of the declining inventory log for Resident #12's Tramadol 50 mg indicated a count of nine tablets and was last signed dispensed on 3/19/23 at 9:15. On 3/20/23 at 10:52 AM, during an interview with the surveyor, LPN/UM #1 stated when a narcotic medication is removed from the bingo card, the declining inventory log is signed immediately. On 3/20/23 at 11:22 AM, the surveyors observed LPN/UM #1 and RN #2 signed the declining inventory sheet and indicated that the Tramadol was wasted on 3/20/22 and included the time. The surveyors observed LPN/UM #1 and RN #2 pour the unlabeled packet of medications for Resident #12 into the drug buster (drug disposal system). The surveyor reviewed the medical records for Resident #12. A review of the admission record reflected the resident was admitted [DATE] with diagnoses that included malignant neoplasm (cancerous tumor) of unspecified site of left female breast, dysphagia (swallowing difficulty), hypertension (high blood pressure), anxiety disorder, and unspecified dementia (memory loss). The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 03/14/23, reflected the resident had a brief interview for mental status (BIMS) score of 00 out of 15, which indicated severely impaired cognition. Section K0100 indicated none for signs and symptoms of possible swallowing disorder. A review of the physician order included an enteral feed order. The eMAR included the following medication that were scheduled to be administered at 9:00 AM: -Diltiazem 30 milligram (mg) -Zinc 50 mg -Hydralazine 50 mg -Tramadol 50 mg 6) On 3/20/23 at 01:23 PM, during the observation of the cycle count for the controlled substance (narcotic) medications stored in the electronic back-up box conducted by the DON and LPN/UM#2, the surveyor observed nine (9) of the 31 tablets of Morphine Extended Release (medication for pain) 15 mg tablets that expired on 02/18/23. At that time, the DON confirmed she also observed nine tablets of Morphine Extended Release (ER) 15 mg tablets that expired on 02/18/23. On 3/20/23 at 01:26 PM, LPN/UM #2 also confirmed she also observed nine (9) tablets of Morphine ER 15 mg tablets that expired on 02/18/23. At that time, the DON stated the 11-7 shift nurse and the 7-3 shift nurse should have reconciled the count and checked for the expiration date of the narcotic medications. The DON stated she would remove the expired Morphine ER 15 mg tablets file the necessary forms with the Drug Enforcement Agency (DEA) prior to the destruction of the expired Morphine ER 15 mg tablets. She stated she would store expired narcotic in her office in a double locked area. On 3/20/23 at 01:36 PM, the DON stated no expired medications should have been present in the electronic back-up machine and the nurses during the shift-to-shift change were responsible. On 3/21/23 at 01:16 PM, in the presence of the survey team, the Regional Clinical Supervisor (RCS), the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor discussed the concerns involving medication storage and administration observations. On 3/22/23 at 11:14 AM, in the presence of the survey team, RCS, LNHA, the DON, stated she attempted to provide education to RN #2 regarding the missed dose during medication pass, not signing the declining inventory log, and the crushed medications left unattended but RN #2 refused to sign. At that time, the DON stated the declining inventory log should have been signed by the nurse for accountability and that was the expectation. At that time, the DON stated an in-service was provided to the 11-7 shift nurses to check for expired medications. The DON stated expired medications would have loss of efficacy for the residents. The DON acknowledged the importance of the back-up medications be in-date which would ensure medications were available for residents when needed. No further information was provided. A review of the facility provided policy Controlled Substance revised April 2022 included under Policy Statement: The facility shall comply with laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances. Section 3. indicated, This record must contain: d. number on hand, j. signature of nurse administering medication. A review of the facility policy provided, Medication Storage revised on 11/22, included under Policy: The facility shall store all medications and biologicals in a safe, secure, and orderly manner. Under section 1. Medications and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Section 3. All medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel. Section 5. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and dispose as per State guideline. A review of the facility provided policy Medication Administration updated 10/2022 included under Policy Interpretation and Implementation section 9. 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. NJAC 8:39-27.1(a), 29.4 (a)(c)(g)(h)(k), 29.7(c)

Complaint # NJ00154046 Based on observation, interview, record review, and review of the facility provided pertinent documents, it was determined that the facility failed to: a) follow through with dental recommendation for a total of eleven (11) months for one (1) of four (4)residents, (Resident#80) reviewed for dental concerns; b) follow the physician's order with regard to blood pressure medications with parameters for one (1) of twenty nine (29) residents, (Resident#24) reviewed for medications; and, c) ensure that resident's weight was obtained and recorded according to the facility's procedure for one (1) of six (6), (Resident#295) reviewed for weights according to the standards of clinical practice. 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 3/22/23 at 9:45 AM, the surveyor observed Resident #80 seated in a regular chair in the room where the resident resided, watching TV (television). The resident stated to the surveyor that at times, he/she felt tooth pain. The surveyor reviewed Resident #80's hybrid medical records and showed the following: The Admission Record (AR; or face sheet; an admission summary) was admitted to the facility with diagnosis that included Epilepsy (happens as a result of abnormal electrical brain activity, also known as seizure), hypertension (elevated blood pressure) and congestive heart failure. The Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, dated 02/22/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. A review of the form titled, [name redacted] dated 4/04/22 revealed that the dentist had seen and examined Resident #80 who also documented under the Treatment Notes, .Recommend Peridex (antibacterial mouthwash) 12% one bottle for swish and spit 10-15 mL (milliliters) for 30 seconds BID (twice a day) after brushing and flossing; On 3/22/23 at 9:50 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that if the dentist had any recommendations after assessing any resident, the dental form will be handed to the nurses on the unit who will then be responsible to call the resident's physician for recommendation approval. The RN/UM further stated that the nurse who called the physician will be expected to document in progress notes. On 3/22/23 at 10:00 AM, the surveyor notified the RN/UM that there were no progress notes found in the electronic medical records regarding the dentist's recommendation. On 3/24/23 at 9:30 AM, the RN/UM showed the surveyor a progress notes documented by the Nurse Practitioner (NP) dated 3/22/23 at 19:54 (7:54 PM) which revealed, General Note 4/04/22 19:54 Late Entry: Note text: Received a call from nurse on unit, Pt (patient) refused peridex mouth wash. Pt was educated on the importance of compliance with prescribed medications. Pt acknowledged understanding. On 3/24/23 at 9:35 AM, the surveyor interviewed Resident #80 who stated to the surveyor that they could not recall any medical practitioner who discussed about a mouthwash. The resident further stated that he/she used the same regular mouthwash since residing in the facility. On 3/24/23 at 10:40 AM, the surveyor informed the facility's Licensed Nursing Home Administrator (LNHA), Regional LNHA, Director of Nursing (DON), and Regional Clinical Supervisor (RCS). The DON stated that any medical practitioner were expected to document the progress notes as soon as possible. The DON further stated that the recommendation from the dentist on 4/04/22 was missed. The Regional LNHA added regarding the NP note which was documented 11 months later as unacceptable. 2. On 3/10/23 at 12:01 PM, the surveyor observed Resident#24 laying on the bed with the head of the bed elevated while tube feeding was infusing via a pump. The surveyor reviewed the medical records of Resident#24 and showed the following: The resident's AR reflected that the resident was admitted to the facility with diagnoses that included unspecified dementia without behavioral disturbance, type two (2) diabetes mellitus without complications (a chronic disease characterized by high levels of sugar in the blood), unspecified systolic (congestive) heart failure (occurs when the heart does not pump blood effectively), essential hypertension (elevated blood pressure), aphasia following cerebral infarction (a loss of ability to produce or understand language due to stroke), and gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach). The 01/18/23 Comprehensive Minimum Data Set (CMDS), revealed cognitive skills for daily decision making were severely impaired. The March 2023 Order Summary Report (OSR) revealed an order date of 02/23/23 for Clonidine HCL (Hydrochloride) oral tablet (tab) 0.1 MG (milligram), to give one tab via G-Tube every four (4) hours (hrs) as needed (PRN) for HTN (hypertension) for SBP (Systolic Blood Pressure; or the top number, is the amount of pressure experienced by the arteries while the heart is beating) 160 or more. The above physician's order for PRN Clonidine was transcribed to the electronic Medication Administration Record (eMAR). A review of the March 2023 eMAR showed that the physician's order to administer the PRN Clonidine was not followed for the following dates when the SBP was above 160: 3/01/23 at Day Shift SBP 164/78 3/10/23 at Night Shift SBP 174/96 3/11/23 at 8 AM SBP 176/96 On 3/16/23 at 11:23 AM, the surveyor interviewed and notified the Licensed Practical Nurse (LPN) of the above findings. The LPN acknowledged that she was the assigned nurse on 3/11/23 that documented the 8 AM SBP of 174/96. The LPN stated that she should have followed the physician's order to administer the PRN Clonidine. She further stated that the PRN order for Clonidine should be clarified because how can a nurse remember that there was an order for PRN Clonidine if the SBP is above 160? She indicated that the order should be changed to a standing order. On 3/16/23 at 12:53 PM, the surveyor asked the DON for a copy of the facility's policy about physician's orders and medication with parameters, and the DON stated that she will get back to the surveyor. On 3/20/23 at 8:33 AM, the surveyor followed up with the DON about the medication with parameters policy, and the DON stated that she will get back to the surveyor. On 3/21/23 at 01:03 PM, the survey team met with the LNHA, DON, and the RCS and were made aware of the above findings. On 3/22/23 at 11:04 AM, the survey team met with the RCS and the DON. The DON stated, for me, the order should have been put in differently, which should have been clarified. A review of the facility's Physician Services Policy with an updated date of 12/2022 that was provided by the DON included that the medical care of each resident is under the supervision of a Licensed Physician and that the physician will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage. There was no facility policy that was provided with regard to medication with parameters that were provided to the surveyor. 31656 3. On 3/20/23, the surveyor reviewed the hybrid closed record for Resident #295 and revealed the following: The AR documented that the resident was admitted on [DATE] with diagnosis that included but were not limited to anemia (low blood count), chronic kidney disease (involves gradual loss of kidney function), type 2 Diabetes, heart failure and unspecified asthma (chronic disease in which airways become narrowed and swollen, making it difficult to breathe). The MDS dated [DATE], section C of the MDS, revealed a BIMS score of six (6) out of 15, suggesting a severe cognitive impairment. The personalized Care Plan (CP) documented a focus of, Resident #295 presents with moderate malnutrition due to significant weight loss, mild body fat loss, mild muscle mass loss, varied oral intake, below unusual body weight, skin impairment, need for supplements. The CP documented interventions which included, Monitor weights and labs (laboratory) as available. This portion of the CP was initiated on 6/29/22. Review of the Admission/Readmission Height and Weight Worksheet found in the resident's paper chart documented the resident's weight on 6/28/22 showed a documentation of 137.6 lbs. via Hoyer Lift (a mechanical device used to transfer a resident). Entries are required and were found blank for Day 2, Day 3, Week 1, Week 2, Week 3, and Week 4. The computerized information located in the Progress Notes and weights section for the time period Resident #295 was admitted to the facility provided no further information documenting weights or attempts to weigh this resident. On 3/21/23 at 10:04 AM, the surveyor interviewed the Registered Dietician (RD) who explained that new admission residents are weighed initially then weekly for 4 weeks and then monthly. The RD added, Dieticians are responsible for acquiring the weights for residents admitted to the facility. The RD explained that she was not working at the facility at the time. No further documentation was submitted to show that the resident was weighed weekly. On 3/23/23 at 11:54 AM , the surveyor interviewed the DON who clarified that the facility is responsible for weighing new admission residents on Day 1, Day 2 and possibly Day 3. Weights are then obtained weekly for 4 weeks thereafter. The DON indicated that the weight information is conveyed to the dietician and the dietician documents and evaluates if there's any modification that needs to be made. No further information was provided. NJAC 8:39-11.2 (b); 29.2 (d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) consistently monitor refrigerator and freezer temperatures and document them in the facility logs and b) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a foodborne illness. This deficient practice was evidenced by the following: On 3/10/22 at 9:59 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In walk-in refrigerator#1, the surveyor observed one of five pitchers of iced tea with a use-by date of 3/05. The pitcher was half full. The FSD stated that it should have been discarded on the use-by date. 2. In the food preparation (prep) area, near the oven, the surveyor observed five knives stocked in between the crease of the prep table and oven, two out of five knives with dried brown and white substances. The FSD asked the Dietary Cook (DC) why the five knives were not properly stored, then, the DC immediately placed the five knives in the knife rack without cleaning it first. 3. The ice scooper was stored with a missing cover attached to the wall near the kitchen office. Above the ice scooper, a ceiling tile with dried black and brown substances. The FSD stated that it was okay for the ice scooper to have no cover. The FSD further stated that the black and brown substances from the ceiling tile were from the accumulated water dripping. On 3/13/23 at 10:25 AM, in the presence of the FSD, the surveyor observed the following: 1. In walk-in refrigerator#2, the surveyor observed the Refrigerator Temperature (temp) Log for March 2023 had two dates with missing temperature and initials for dates 3/12/23 and 3/13/23 for AM (morning) temp. 2. In freezer#1, 3, and 4, the surveyor observed the Freezer Temperature Log for March 2023 had two dates missing temp and initials for dates 3/12/23 and 3/13/23 for AM temp. 3. In freezer#2, the surveyor observed the Freezer Temperature Log for March 2023 had two dates missing temp and initials for dates 3/12/23 and 3/13/23 for AM temp. 4. In the dry storage room, the surveyor observed eight (8) pieces of hotdog buns in a plastic bag with no date. The hotdog buns had no molds. The FSD stated that the hotdog buns should have a use by date. The FSD was unable to state the delivery date of the hotdog buns. The surveyor reviewed the delivery receipts that were provided by the Regional Dining Services (RDS) dated 3/13/23 and showed that there was no delivery for hotdog buns for that day. On 3/21/23 at 9:00 AM, the surveyor interviewed the DC. The DC informed the surveyor that the cook was responsible for checking and logging refrigerator and freezer temperatures when he comes at five (5) AM. The DC stated that the ice scooper should have a cover. He acknowledged that he worked on 3/10/23, 3/12/23, and 3/13/23, and he should have logged the temps for the refrigerator and freezers. He further stated that on 3/12/23 and 3/13/23 (Sunday and Monday) for AM shift he was not able to log temps because of short staff. On that same date and time, the DC stated that on 3/10/23, I was hurrying up, because he heard that the surveyors entered the facility and stocked the unclean knives in between the crease of the oven and prep table. He further stated that he should not store the unclean knives back in the rack and should have washed them first. On 3/21/23 at 01:03 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Clinical Supervisor (RCS) and were made aware of the above findings. On 3/22/23 at 11:04 AM, the survey team met with the RCS and the DON and the surveyor followed up on responses from yesterday's (3/21/23) findings from the kitchen. The DON stated that she was not the right person to respond to kitchen concerns. On 3/23/23 at 01:29 PM, the survey team met with the Associate Regional Director (ARD), LNHA, DON, and the RCS. The surveyor asked and followed up regarding the kitchen findings, and if the facility had a response. The ARD stated that he will get back to the surveyor. A review of the undated Ice Policy that was provided by the RDS included that Ice will be prepared and distributed in a safe and sanitary manner, and ice scoops will be cleaned and stored in a separate container. A review of the undated Manual Warewashing Policy that was provided by the RDS included that all serviceware and cookware will be air-dried prior to storage. The surveyor reviewed the undated Warewashing Policy that was provided by the RDS and showed that all dishware, serviceware, and utensils will be cleaned and sanitized after each use. A review of the facility's Food Storage: Cold Foods Policy with a revised date of 4/2018 that was provided by the RDS revealed that the freezer temperatures will be maintained at a temperature of 0 degrees Fahrenheit or below, an accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. On 3/24/23 at 10:36 AM, the survey team met with the LNHA, Regional Administrator, DON, and the Regional Dietician. There was no additional information provided by the facility team regarding kitchen concerns. NJAC 8:39-17.2(g)

Based on the interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to conduct COVID-19 testing for two (2) of two (2) residents (Residents#132 and #39) and 16 of 16 staff identified as close contacts following a staff member testing positive for COVID-19 in accordance with the facility's policies and Centers for Disease Control and Prevention (CDC) guidelines for infection control and to mitigate the spread of COVID-19 (a deadly, highly transmissible infectious disease). The deficient practice was evidence by the following: Reference: According to the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic with an updated date of Sept. 23, 2022, included the following: Perform SARS-CoV-2 Viral Testing Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 . Nursing Homes . Responding to a newly identified SARS-CoV-2-infected HCP [Healthcare Personnel] or resident When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP [Healthcare Personnel] identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 . On 3/13/23 at 8:45 AM, the Director of Nursing (DON) provided the contact tracing for a staff member, Dietician #1, who tested positive for COVID-19 on 3/07/23. The document was titled COVID-19 Contact Tracing [a facility assessment tool], dated 3/08/23, which included the following information: the staff member who tested positive, the last day the staff member worked, the day they tested positive, if the staff member had symptoms, if the staff member was vaccinated, and questions about potential exposure to COVID-19 prior to testing positive. The document indicated the staff member last worked at the facility on 3/06/23. On 3/20/23 at 11:21 AM, the surveyor interviewed the Infection Control Preventionist Nurse (ICPN), who stated that the DON conducted the contact tracing follow up for Dietician #1 and that she was not at work during the time to complete the contact tracing. The ICPN stated there was a binder where COVID-19 test results were kept and that residents' test results could be found in their medical records. On 03/20/23 at 11:55 AM, the surveyor interviewed the DON, in the presence of the Regional Director of Clinical Services (RDCS) about contact tracing and COVID-19 testing protocols. The DON stated when there was a known positive COVID-19 staff or resident, contact tracing was done to determine residents or staff who have been exposed to the positive COVID-19 individual. The DON further stated if they were unable to determine the individuals exposed from contact tracing, facility wide testing would be conducted. At that same time, the DON confirmed for the positive COVID-19 staff member on 3/07/23, contact tracing was conducted, exposed staff and residents identified were tested . The surveyor asked the DON the frequency of testing for exposed staff and residents identified as close contacts. The RDCS replied to the surveyor testing was to be conducted day 1 (one), 3 (three), and 5 (five) after an individual tested positive for COVID-19. The DON was asked to provide testing documentation for the identified close contacts from the contact tracing conducted. On 3/21/23 at 11:05 AM, the DON provided the surveyor with staff COVID-19 testing results for staff and residents tested after contact tracing was conducted for the COVID-19 positive staff member. A review of provided documents revealed a form titled, COVID-19 POC Antigen Test for each person identified through contact tracing, which included the resident/staff member's name, test kit information, date of the test, and the test results. The provided COVID-19 test results for the residents and staff members were dated 3/08/23 and then for the following week on 3/14/23 and 3/15/23. On 3/23/23 at 9:50 AM, the surveyor interviewed Dietician #1 who tested positive for COVID-19 on 3/07/23. Dietician #1 confirmed she last worked on 3/06/23 in the building. She stated on 3/07/23 she had body pain, congestion, fever, did not come to the facility, and worked from home. Dietician #1 stated she went to the doctor on the same day and was tested for COVID-19, which came back positive. Dietician #1 stated she notified the DON who asked questions about which residents she had contact with, staff she had meetings with, when the symptoms started, and her potential source of exposure to COVID-19. Dietician #1 stated from 3/07/23 to 3/16/23 she worked from home and returned to work on 3/17/23 when she no longer had symptoms for more than 3 (three) days. On 3/23/23 at 10:09 AM, the surveyor interviewed the DON about infection control protocols, including contact tracing and COVID-19 testing. The DON stated the facility's infection control practice was based on the facility policies, along with CDC, state, and local guidelines. On that same date and time, the DON stated the dietician notified her on 3/08/23 that she had tested positive for COVID-19. The DON stated she asked Dietician #1 about her symptoms, when her symptoms started, where she may have been exposed to COVID-19, and close contacts she had in the facility. The DON stated Dietician #1 reported two residents (Resident #132 and Resident #39) as close contacts, but all the residents on the unit were tested as a precaution. The DON further stated staff who were in close contact with Dietician #1 were tested . At that time, the surveyor asked the DON when the identified residents and staff were tested . The DON replied on 3/08/23 and the following week on 3/15/23. The surveyor then asked the DON about the facility's policy for testing of identified close contacts after a staff or resident tested positive for COVID-19. The DON replied once a week. The surveyor asked the DON about CDC guidelines for testing. The DON did not provide a verbal response to the question. Furthermore, the DON stated all residents and staff were asymptomatic. The surveyor reviewed with the DON the facility's outbreak plan provided to the survey team, which revealed testing after a positive staff/resident and identification of close contacts indicated testing should be completed on day 1, 3 and 5. The DON stated she would look into providing further information to the surveyor and that the policy might not be up to date. On 3/23/23 at 01:29 PM, the surveyor notified the DON, the Licensed Nursing Home Administrator (LNHA), the Regional Clinical Supervisor (RCS), and the Associate Regional Director about the above findings. The RCS acknowledged that the facility's testing policy was to be conducted on Day 1 (one), 3 (three) and 5 (five). The facility stated they would provide further information. On 3/24/23 at 10:43 AM, the DON provided the list COVID-19 testing for residents and staff for the COVID-19 positive staff on 3/07/23. A review of the documents revealed testing for residents and staff identified as close contacts occurred on 3/08/23, 3/14/23, and 3/15/23. No further documentation was provided regarding COVID-19 testing. On 3/27/23 at 12:27 PM, the surveyor spoke with the DON, in presence of RCS, who acknowledged the facility policy was to test identified resident and staff after a positive COVID case on day 1 (one), day 3 (three) and day 5 (five). The surveyor asked the DON who was responsible for contact tracing and COVID-19 testing. The DON stated the ICPN was responsible. The surveyor asked who was responsible for overseeing and ensuring that the ICPN was carrying out her responsibilities. The DON replied I am and the Administrator. A review of the facility's policy titled Policy for Emergent Infectious Diseases (COVID-19) (Outbreak Plan V10), with an updated date of 11/21/22, included the following: Test Based Prevention Strategy . Asymptomatic patients with close contact with someone with SARS-CoV-2 infection . Testing is recommended immediately (but not earlier than 24 hours after the exposure) and if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. Day 1 (where day of exposure is day 0), day 3, and day 5 Testing of Residents and Staff as follows: 2. If there is a new identified COVID-19 positive staff or resident in a facility that can identify close contacts, then: Residents: regardless of vaccination status, who had close contact with a COVID-19 individual must be tested . Staff: regardless of vaccination status, that had a higher-risk exposure with a COVID-19 positive individual must be tested . Testing is completed on Day 1-Day 3-Day 5 or in accordance with the recommendations by local health department (LHD). N.J.A.C. 8:39-5.1(a), 19.4 (a)

Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff for two (2) of two (2) facility areas observed for an environmental tour (laundry area and resident rooms) according to facility and standard of clinical practice. This deficient practice was evidenced by the following: On 3/16/23 at 11:49 AM, the surveyor toured the laundry area in the presence of the Laundry Service Director (LSD). The surveyor observed a commercial size trash can in the middle of the laundry room dryer area. The depth of water collection in the commercial trash can was approximately 5 (five) inches deep. The leak is in the folding and preparing laundered personal resident clothing area. There was a rack of clean clothes of residents that were not covered near the open ceiling tile with a leak. On that same date and time, the LSD stated that the leak in the laundry dryer area had been there since he was hired in mid-January. The LSD further stated, the trash receptacle is being used to collect the water from the ceiling leak. The LSD was unable to answer if it was clean water or dirty water that was leaking. During an interview on 3/16/23 at 12:00 PM with the surveyor with Maintenance Personnel (MP), the MP stated, the leak is being caused by a resident's room on the C-Wing above. It has a cracked pipe behind a tiled wall and that the plumber is aware of. In an interview on 3/16/23 at 12:30 PM with the Head of Maintenance (HOM), Licensed Nursing Home Administrator (LNHA), and Regional LNHA, all acknowledged the leak in the laundry dryer room area and that it has been there since 12/25/22. The LNHA stated, there is numerous email correspondence with the plumber and facility management. The HOM stated, that there is no scheduled date for it to be fixed, the leak is confirmed to be a crack in an interior pipe and the water line is clean water not dirty. On that same date and time, the surveyor notified the Regional LNHA, LNHA, and HOM of the above findings. The Regional LNHA stated that the tub on the C-wing should be white in color and clean. The Regional LNHA further stated that the toilet should not be actively running with water. On 3/16/23 at 12:49 PM, the surveyor observed in the presence of the LNHA and Regional LNHA, a shared bathroom between two resident rooms C1 and C2, the toilet continuously ran with water, with brown decolorization watermarks on the inside of the bowl. On that same date and time, the surveyor observed in the presence of the LNHA and Regional LNHA, a shared bathroom between two resident rooms C1 and C2, the faucet continuously leaked in the tub. The faucet had black-colored sediment flaking off the rim of the spout and the interior of the tub was discolored with brown and black streaks down the side and around the drain. On 3/27/23 at 12:00 PM, the surveyor interviewed the LNHA in the presence of other surveyors. The LNHA stated that there was no set schedule yet to fix the leak in the laundry room. A review of the provided email chain by the LNHA revealed that the concern leak in the laundry room started on 12/25/22 and the HOM was notified. Further review of the provided email chain response by the LNHA showed that the succeeding email was sent on 02/26/23 at 12:17 PM with a notification to HOM questioning the progress of the leak as it was still an issue. A review of the Personal Property policy, updated on 10/2022, provided by the DON, did not reflect the environment in its verbiage. A review of the Laundry Operations policy, revised on 6/2016, provided by the LNHA, did not reflect the environment in its verbiage. N.J.A.C. 8:39 -31.2 (e)

Based on observation, interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to follow and maintain fall prevention interventions as ordered by the physician and as written on the resident's plan of care for one (1) of three (3) residents (Resident #94) reviewed for accidents. This deficient practice was evidenced by the following: On 3/10/23 at 10:36 AM, the surveyor observed Resident #94 lying in a low to the floor bed. The surveyor observed a blue floor mat that was upright on its side leaning against the right side of the bed. The surveyor did not observe a floor mat on the left side of the bed or anywhere else in the room. Resident #94 did not respond to the surveyor. On 3/16/23 at 10:50 AM, the surveyor observed Resident #94, with the bed sheet over the resident's head, lying in a low to the floor bed. The surveyor observed a blue floor mat that was upright on its side leaning against the right side of the bed. The surveyor did not observe a floor mat on the left side of the bed or anywhere else in the room. On 3/16/23 at 11:37 AM, the surveyor, in the presence of another surveyor, observed Resident #94, lying in a low to the floor bed. The surveyors observed a blue floor mat that was upright on its side leaning against the right side of the bed. The surveyors did not observe a floor mat on the left side of the bed or anywhere else in the room. The surveyor reviewed Resident #94's medical record and revealed the following: The Admission Record (or face sheet; an admission summary) indicated that the resident had diagnoses which included but were not limited to unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), polyostearthritis (degenerative joint disease) and anemia (condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues). The admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 01/19/23, reflected a Brief Interview of Mental Status (BIMS) score of 0 (zero) out of 15 which indicated severe cognitive impairment. The active Order Summary Report dated 3/22/23, reflected a physician's order dated 3/09/21, for bilateral floor mats when in bed every shift for s/p (status post) fall. A review of the resident's individualized care plan reflected a focused area dated 02/08/21, that the resident had an actual fall with no injury r/t (related to) poor balance and cognitive impairment. Interventions included but were not limited to, bilateral floor mats when in bed with an initiated date of 3/09/21. On 3/16/23 at 11:54 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) regarding Resident #94. The CNA stated that the resident was at risk for falls and that she checked on the resident often. The surveyor asked the CNA what the purpose was for floor mats. The CNA stated that floor mats were used to prevent injury. On 3/16/23 at 11:58 AM, the surveyor asked the Licensed Practical Nurse (LPN) and the CNA to enter Resident #94's room to observe how the one floor mat was placed on its side and not flat on the floor. The LPN and CNA confirmed that the placement of the one floor mat was not correct. The surveyor asked the LPN how an order for bilateral floor mats should be placed. The LPN stated that the floor mats should be placed on both sides of the bed on the floor. She added that the reason was in case the resident fell out of bed the mats would protect them. The CNA added that the staff on 3-11 shift usually put them down. On 3/16/23 at 12:02 PM, the surveyor asked the A wing Unit Manager (UM) what the expectation of floor mats were. The UM stated that floor mats should be in place at the resident's bedside, flat on the floor. On 3/16/23 at 12:04 PM, the surveyor and the UM went to Resident #94's room. The surveyor asked the UM if the floor mat that was observed was supposed to be upright. The UM stated that the floor mat was not supposed to be upright and that it should be flat on the floor. The surveyor asked the UM if there was a second floor mat in the resident's room. The UM confirmed that there was only one floor mat. She then proceeded to place the one floor mat flat on the floor on the right side of the resident's bed. On 3/21/23 at 01:09 PM, the surveyor, in the presence of the survey team, notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional Clinical Supervisor (RCS) the above findings that Resident #94's floor mats were not appropriately placed according to a physician's order during multiple observations. On 3/22/23 at 11:25 AM, in the presence of the survey team and the RCS, the DON stated that she looked into Resident #94's floor mats and that the resident had the floor mats but that when the CNA provides care they sometimes forgot to put them down. She added that the CNA does not want to step on them [floor mats]. At that same time, the surveyor notified the DON that there was only one floor mat in the room during all observations and that the staff had confirmed that there was only one floor mat. The surveyor then asked the DON if there should have been two floor mats in the room and placed flat on the floor. The DON stated that there should have been two floor mats and that they should have been down on the floor. A review of the facility provided policy titled, Falls and Fall Risk, Managing with an updated date of 10/2022, included the following: Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several potential interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once) . 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to: a) administer Tube Feeding (nutrition received through a flexible tube surgically inserted into the stomach) per the physician's order, b) document the total volume (TV) according to physician's order, and c) properly label the Tube Feeding (TF) bag according to the standard of clinical practice. This deficient practice was identified for one (1) of two (2) residents, (Resident #24) reviewed for receiving nutrition via TF and was evidenced by the following: On 3/10/23 at 11:52 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that Resident #24 was on TF. On 3/10/23 at 12:01 PM, the surveyor observed the resident laying on the bed with the head of the bed elevated, and non-verbal. The surveyor observed that the resident had a TF formula hanging on a pole, attached to a TF pump, and infusing at a rate of 75 ml/hr (milliliters per hour). The resident's Admission Record (or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Unspecified Dementia without behavioral disturbance, type two (2) diabetes mellitus without complications (a chronic disease characterized by high levels of sugar in the blood), unspecified systolic (congestive) heart failure (occurs when the heart does not pump blood effectively), essential hypertension (elevated blood pressure), aphasia following cerebral infarction (a loss of ability to produce or understand language due to stroke), and gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach). The 01/18/23 Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate care management, revealed cognitive skills for daily decision-making were severely impaired. The 01/18/23 CMDS revealed that the resident had a TF. The March 2023 Order Summary Report (OSR) revealed a physician's orders as follows: Order date 02/23/23 7:44 AM and d/c (discontinue) date 3/10/23 5:21 PM for Enteral feed order one time a day Fibersource HN (a nutritionally complete tube feeding formula with fiber) at 75 ml/20 hr continuous up at 4 (four) PM and down once TV (total volume): 1500 ml/day is infused-providing 1800 kcal/day (kilo calorie per day), 81 g (gram) of PRO (protein). Order date 3/10/23 at 5:21 PM Enteral feed order one time a day Fibersource HN at 80 ml/18 hr continuous up at 4 PM and down once TV: 1440 ml/day is infused, providing 1728 kcal/day, 77.8 g of PRO. The above order for Fibersource HN was transcribed into an electronic Medication Administration Record (eMAR) and signed as administered daily in the March 2023 eMAR. The enteral feed order total volume infused in 24 hrs amount was documented from 3/11/23 through 3/19/23 for a TV of 1500 ml by nurses. Further review of the medical records showed that the physician's order on 3/10/23 for Fibersource HN TV of 1440 ml/day was not followed as shown on the March 2023 eMAR signed by nurses from 3/11/23 through 3/19/23 as 1500 ml TV. On 3/23/23 at 8:32 AM, the surveyor observed the resident laying on the bed with the head of the bed elevated with eyes closed. The TF was infused via a pump hung on a pole at 70 ml/hr with a total fed (TV) at 1134 ml registered on the pump machine. At that same date and time, the surveyor immediately looked for the assigned nurse and went to the B unit nursing station. The Unit Clerk (UC) informed the surveyor that the nurse was probably in another resident's room. Then, the surveyor asked for the LPN/UM, and the UC responded that she will get back to the surveyor. On 3/23/23 at 8:37 AM, the surveyor interviewed the LPN/UM, and later on, Licensed Practical Nurse#1 (LPN#1) came. The surveyor asked the LPN/UM and LPN#1 regarding the resident's order for TF. LPN#1 informed the surveyor that she was not the one who hung the TF because it was ordered to start and hung at four (4) PM, and was not the nurse who set up the TF, it was the 3-11 PM shift nurse from yesterday (3/22/23). The LPN further stated that she had to check first the eMAR for the actual order. On that same date and time, both the surveyor, LPN/UM, and LPN#1 went inside the resident's room and observed that the resident's TF was infusing at a rate of 70 ml/hr. The resident's TF bag that was hung on the pole had the resident's name, date and time started (3/22/23 at four (4) PM). The TF bag had incomplete information because the TF order (ml/hr rate) was left blank. Afterward, the surveyor followed the LPN/UM in the B unit nursing station to check the resident's order for TF. LPN#1 left and continued her medication administration to other residents. The LPN/UM stated that the resident's order for TF was Fibersource HN at 80 ml/hr continuous up at four (4) PM and down once TV 1440 ml/day is infused. Furthermore, the LPN/UM stated that LPN#2 was the one who worked on 3/22/23 and hung the TF of the resident. The LPN/UM indicated that she will get back to the surveyor for LPN#2's phone number. The surveyor asked the LPN/UM why the order was not followed for TF, and the LPN/UM stated that I do not know these nurses, they are not checking. On 3/23/23 at 8:43 AM, the surveyor observed the resident in their room with TF infusing at 70 ml/hr, TV fed 1148 ml with 292 ml remaining to be infused according to the TF pump machine monitor. On 3/23/23 at 8:50 AM, the surveyor observed the Director of Nursing (DON) inside the resident's room and checked the TF machine that was infusing at 70 ml/hr at that time. The surveyor observed the DON wrote 70 ml/hr at the TF bag where the blank information for the TF order was previously seen by the surveyor and the LPN/UM. On that same date and time, the surveyor interviewed the DON after the DON left the resident's room. The DON stated that she did not know who changed the TF because she left around 4:30 PM yesterday (3/22/23) and had checked the resident to make sure that the TF was on the right TV according to the physician's order. The DON further stated that she had to make sure that the nurses are documenting and following the TV after the surveyor's inquiry on why the TV of 1440 ml/day for 80 ml/hr was not followed as seen on the March 2023 eMAR that nurses were documenting TV of 1500 ml/day. The surveyor asked the DON why she wrote 70 ml/hr on the TF bag if the physician's order was 80 ml/hr, and the DON did not respond. Furthermore, the DON informed the surveyor that when she checked the TF yesterday (3/22/23) before leaving the facility, the TF rate was wrong and that she had to correct it, that was why she did not know who changed the rate again to 70 ml/hr. She further stated that the nurses who signed 1500 ml TV were just not checking. On 3/23/23 at 9:19 AM, the surveyor interviewed LPN#1. LPN#1 showed the surveyor how to operate the TF pump machine and explained that the TF machine shows the rate (ml/hr), TV fed, and the lower rate was the remaining TV to be infused. LPN#1 showed also that the nurse who initiated the four (4) PM TF will set up also the TV in the machine. LPN#1 acknowledged that the rate should have been at 80 ml/hr and the TV was 1440 ml. LPN#1 stated that the physician's order for 80 ml/hr and 1440 ml should have been followed. On that same date and time, the LPN/UM came and checked the TF bag and stated that the 70 ml/hr was not written earlier when both the surveyor and LPN/UM checked the resident. The LPN/UM further stated that she did not know who wrote that rate on the TF bag. The surveyor notified the LPN/UM that it was the DON who was inside the resident's room earlier. On 3/23/23 at 9:52 AM, the surveyor called LPN#2 for an interview, and LPN#2 did not respond to the call. On 3/23/23 at 01:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Associate Regional Director (ARD), DON, and Regional Clinical Supervisor (RCS), and were made aware of the above findings. The DON stated that the facility recognized an oversight for TF for not following the 80 ml/hr and not documenting 1440 ml TV in the March 2023 eMAR, I'm lost for words. On 3/24/23 at 10:36 AM, the survey team met with the LNHA, DON, Regional Administrator (RA), and Regional Dietician. At that same time, the Regional Dietician stated that when Resident #24 was admitted to the facility, it was the Regional Dietician who did the resident's nutrition assessment. She further stated that the resident came in with edema (swelling caused by too much fluid trapped in the body's tissues), later, was noted with weight loss, stabilized, then was transferred back to the hospital. The Regional Dietician informed the survey team that when the resident came back from hospitalization , the resident was reassessed, and TF was adjusted to keep the resident stable. Furthermore, the Regional Dietician stated that the resident was on 80 ml/hr for 18 hrs/day with a total of 1440 ml. The Regional Dietician acknowledged that the physician's order for TF should have been followed. The Regional Dietician further stated that there was no negative effect on the resident. A review of the undated facility's Basic Guidelines for Enteral Feeding Policy that was provided by the DON included that TF should be delivered by nursing as ordered by a physician, and all changes in TF should be accompanied by a physician's order. On 3/28/23 at 12:03 PM, the survey team met with the LNHA, RA, and DON, and there was no additional information provided by the facility team. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to maintain the necessary respiratory care and services for a resident who was receiving oxygen (O2) treatment according to standards of practice. This deficient practice was identified for one (1) of one (1) resident (Resident #24) reviewed for respiratory care. This deficient practice was evidenced by the following: On 3/10/23 at 12:01 PM, the surveyor observed Resident#24 laying on the bed with the head of the bed elevated, and non-verbal. The surveyor observed that the resident had oxygen in use at 2LPM (two liters per minute) via a nasal cannula (consisting of two hollow prongs projecting from a hollow face piece) attached to a humidified oxygen concentrator (a medical device that gives extra oxygen). The resident's Admission Record (or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Unspecified Dementia without behavioral disturbance, type two (2) diabetes mellitus without complications (a chronic disease characterized by high levels of sugar in the blood), unspecified systolic (congestive) heart failure (occurs when the heart does not pump blood effectively), essential hypertension (elevated blood pressure), aphasia following cerebral infarction (a loss of ability to produce or understand language due to stroke), and gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach). The 01/18/23 Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate care management, revealed cognitive skills for daily decision-making were severely impaired. The CMDS did not reflect that the resident was on oxygen. A review of the March 2023 Order Summary Report revealed that there was no order for oxygen. The personalized care plan did not reflect that the resident was on oxygen and there were no interventions for respiratory care. The Progress Notes (PN) for Skilled Charting dated 3/12/23 electronically signed by the Licensed Practical Nurse (LPN) revealed that the resident was on 3LPM via NC (nasal cannula). The PN with an effective date of 3/13/23 at 10:26 PM showed that the Registered Nurse (RN) documented that Resident #24 was in bed, head of the bed elevated, and with O2 at 2LPM via NC. On 3/16/23 at 10:40 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) regarding the care plan and O2 use. The LPN/UM informed the surveyor that the resident on O2 should have an order and care plan. The LPN/UM stated that the care plan and physician order for O2 should be initiated on admission and when the resident started to use the O2. On that same date and time, the surveyor notified the LPN/UM of the above findings. The surveyor asked the LPN/UM why the resident had no order and care plan for O2 when the surveyor observed the resident with O2 in use on 3/10/23 and nurses documented on 3/12/23 and 3/13/23 the resident with O2 use, and the LPN/UM stated: I do not know. The LPN/UM acknowledged that the resident had been using the O2 and was unable to state when the resident started to use the O2. Furthermore, the LPN/UM stated that it was the nurse's responsibility, specifically the UM and the DON to initiate the care plan for the resident. On 3/21/23 at 01:03 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and Regional Clinical Supervisor (RCS) and were made aware of the above findings. On 3/22/23 at 11:04 AM, the survey team met with the RCS and the DON. The DON discussed the resident's other concerns except for the O2 findings. The surveyor followed up with the facility team about what happened and why the resident was seen with O2 in use with no order and no care plan. The DON stated, can I get back to you with that? A review of the facility's Care Plans, Comprehensive Person-Centered Policy with an updated date of 10/2022 that was provided by the DON included that the resident population in the long-term and sub-acute care plans need to be initiated on admission, after significant clinical changes and updated as needed. UM will be responsible to oversee the care plans that are being reviewed periodically by nursing staff. Care plan problems are to be identified on admission, through interdisciplinary, and after significant clinical areas arise. Standardized care plans are to be modified on the computer to meet the clinical needs of the resident. A review of the facility's Respiratory Management Policy updated 2023 that was provided by the DON included that patients will be assessed for the need for respiratory services as part of the nursing assessment process. On 3/28/23 at 12:03 PM, the survey team met with the LNHA, Regional Administrator, and DON, and there was no additional information provided by the facility team. NJAC 8:39-11.2 (e)(1)(2)

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation conducted on 3/20/23, the surveyor observed four (4) nurses administer medications to four (4) residents. There were 29 opportunities, and two (2) errors were observed which resulted in a medication error rate of 6.9%. This deficient practice was identified for two (2) of four (4) nurses that administered medications to two (2) of four (4) residents (Resident #344 and Resident #31) and was evidenced by the following: 1) On 3/20/23 at 8:48 AM, the surveyor observed the Licensed Practical Nurse (LPN) take Resident #344's vitals, exited the room and cleaned the blood pressure cuff. On 3/20/23 at 8:53 AM, the surveyor observed the LPN prepare medications for Resident #344. The medications included the following: - Docusate 100 milligram (mg), 1 (one) tablet two times a day for constipation - Pantoprazole (or Protonix, a medication used to treat certain stomach and esophagus problems) 40 mg, 1 (one) tablet orally two times a day -Heparin 5000 unit/milliliters (ml), Inject 5000 unit subcutaneously every 12 hours for VTE (venous thromboembolism; a medication used to prevent a blood clot formation in the vein) -Ciprofloxacin ophthalmic solution 0.3%, Instill 1 (one) drop in left eye every 4 (four) hours for eye infection for 6 (six) days. Give while awake. -Metoprolol Succinate oral capsule extended release (ER) 24-hour sprinkle 25 mg, 1 (one) capsule orally one time a day for HTN (hypertension; high blood pressure) hold if systolic blood pressure is less than 100, HR (heart rate) less than 60. Give with meals. At that time, the LPN stated she would hold the administration of Metoprolol since breakfast had not arrived to be served to the residents in the unit. On 3/20/23 at 9:03 AM, the surveyor observed the LPN was about to administer the Ciprofloxacin eye drop into Resident #344's right eye. The surveyor stopped the LPN from continuing the medication administration of the Ciprofloxacin eye drop and asked the LPN to review the physician order (PO) for that medication. On 3/20/23 at 9:07 AM, the surveyor and the LPN reviewed the electronic medication administration record (eMAR) for the Ciprofloxacin. The LPN confirmed the eMAR indicated to administer the Ciprofloxacin eye drop into the left eye only. At that time, during an interview with the surveyor, the LPN stated it was important for medications to be administered as ordered because it could have caused side effects and, in this case, antibiotic resistance. The surveyor reviewed the medical records for Resident #344. The Admission Record (face sheet, an admission summary) reflected, Resident #344 was admitted to the facility with diagnoses that included, unspecified acute conjunctivitis (eye infection) left eye, unspecified cataract. The admission Minimum Data Set (aMDS), an assessment tool used to facilitate the management of care, dated 3/19/23, reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated that the resident was cognitively intact. The resident's electronic Medication Administration Record (eMAR) reflected a PO dated 3/14/23, for Ciprofloxacin ophthalmic solution, instill 1 (one) drop in the left eye every 4 hours for eye infection for 6 days. Give while awake. 2) On 3/20/23 at 10:45 AM, the surveyor observed the Registered Nurse (RN) prepare medications for Resident #31. The medications included the following: -Aspirin 81 mg enteric coated, 1 (one) tablet daily -Ferrous Sulfate (iron vitamin) 325 mg, 1 (one) tablet daily -Lamotrigine (used to treat seizures) 25 mg, 1 (one) tablet every 12 hours -Levetiracetam [Keppra] (used to treat seizures) 750 mg, 2 (two) tablets every 12 hours -Lisinopril (used to treat HTN) 20 mg, 1 (one) tablet in the morning -Magnesium Oxide (supplement) 420 mg, 1 (one) tablet two times a day -Multi-vitamin/Minerals, 1 (one) capsule one time a day - Cyclosporine emulsion (helps to increase tear production) 0.05%, instill 1 (one) drop in both eyes every 12 hours for dry eye On 3/20/23 at 11:00 AM, the RN stated she had 7 (seven) pills in the medication dose cup and the cyclosporine eye drop container. On 3/20/23 at 11:05 AM, the RN confirmed with the surveyor that she was ready to administer medications to Resident #31. On 3/20/23 at 11:07 AM, the RN and the surveyor entered Resident #31's room. The surveyor stopped the RN from continuing the medication administration and asked the RN to review the PO. On 3/20/23 at 11:08 AM, the surveyor and the RN reviewed the eMAR for the Levetiracetam. The RN stated she should have prepared to administer two (2) tablets instead of one (1) tablet. At that time, the RN stated it was important to administer the medication as ordered and in this case the resident had a history of seizure. Administration of a lower dosage to the resident could have resulted in breakthrough seizures. The surveyor reviewed the medical records for Resident #31. A review of the admission record reflected, Resident # 31 was admitted to the facility on [DATE] with diagnosis that included, other seizures, unspecified sequelae of cerebral infarction and cognitive communication deficit. According to the aMDS, dated [DATE], reflected that the resident had a BIMS score of 6 (six) out of 15 which indicated that the resident had a severely impaired cognition. The resident's Clinical Physician Orders reflected a PO dated 02/13/23 for Levetiracetam 750 mg, give 2 (two) tablets every 12 hours for seizures. A review of the resident's eMAR reflected Levetiracetam 750 mg, give 2 (two) tablets every 12 hours for seizures, order dated 02/13/23 with an administration schedule at 09:00 AM and 21:00 PM. On 3/21/23 at 01:16 PM, in the presence of the survey team, the Regional Clinical Supervisor (RCS), the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns involving the medication administration observation. On 3/22/23 at 11:14 AM, in the presence of the survey team, the RCS, and the LNHA, the DON stated she attempted to provide education to the RN who refused to sign. No further information was provided. A review of the facility provided policy Medication Administration updated 10/2022 included under Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation included the following: 2. Medications 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 frame unless otherwise specified (for example, before and after meal orders). 5. The individual administering the medication must check the label against the Physician's orders to verify the right resident, right medication, right dosage, right time, right method (route) of administration before giving the medication. 12. New personnel authorized to administer medications will not be permitted to prepare or administer medication until they have been oriented to the medication administration system used by the facility. NJAC 8:39-11.2(b), 29.2(d)

Complaint # NJ 4, NJ 5 CROSS REFERENCE F323 Based on interviews, and review of the medical record (MR) and other facility documentation, it was determined that the facility staff failed to develop an individualized plan of care for 1 of 3 sampled residents (Resident #1) identified as having exit seeking behaviors. On 5/12/2017, Resident #1 verbalized to staff she was leaving and it was documented in the progress notes (PN) trying to leave the building. Additionally, on 5/29/2017, Resident #1 was pacing back and forth to the main door, and packing her clothing into plastic bags. On 6/4/2017, Resident #1 exited the facility and was found sitting on the grass by the entrance of a school about 0.5 miles away from the facility by facility staff. There was no indication in the MR that an elopement care plan (CP) was put into place when the resident was exhibiting exit seeking behaviors on the 2 occasions prior to the resident's actual elopement on 6/4/2017. Review of the facility's policy titled, OP416 Person-Centered Care Plan, dated 11/23/16, included but was not limited to; 4.1 The care plan must be customized to each individual patient's preferences and needs. 5. Care plan will be: 5.1 Communicated to appropriate staff, patient, HCDM (Health Care Decision Maker), family. 5.2 Reviewed and revised a minimum of quarterly and as needed to reflect the response to care and changing needs and goals 5.3 Documented on the Care Plan Evaluation Note. The facility's failure to initiate a CP and ensure the safety of residents who were exhibiting exiting seeking behaviors placed Resident #1 and all residents with exit seeking behaviors in an Immediate Jeopardy (IJ) situation. The Administrator and Director of Nursing (DON) were notified of the IJ on 6/14/2017, at 2:00 p.m. The IJ began on 6/4/2017 when Resident #1 was observed outside of the facility at approximately 11:20 a.m. 1. CROSS REFERENCE F323 , See Example #1. The Administrator and Director of Nursing (DON) were notified of the IJ on 6/14/2017, at 2:00 p.m. The IJ began on 6/4/2017 when Resident #1 exited the facility and was lifted on 6/14/2017 at 3:58 p.m., when an acceptable plan of correction was implemented as evidenced by the following; 1. Resident was reassessed for elopement: elopement protocol and care plan were initiated on 6/4/(17) Team reviewed, revised and updated all the care plans for residents at risk of elopement to reflect the current status. 2. All Resident in the facility are at risk to be affected by this practice. 3. On 6/14/(17) Staff were in-serviced, and will continue quarterly as needed on: 1. communication of residents/patients change in status during shift to shift report. 2. policy and procedure on care plan 3. Identification, documentation and reporting of changed in status IDCP will review the 24 hour report during the morning meetings and update care plans as needed. All residents Care plans will be reviewed by the IDCP team members and updated accordingly with appropriate interventions during care initial, quarterly plan meeting. Care plans will be initiated upon admission, new [DIAGNOSES REDACTED]. meeting, quarterly, and annual also during significant changes as needed. 4. Unit manager or designee will audit weekly new admission charts to assure assessments and change in status are care planned and updated accordingly and report to the DON/Designee. DON/Designee will review findings and follow up Biweekly x 3 months. All findings of audits will be reviewed during monthly and quarterly CQI meeting. NJAC 8:39-11.2 (e) (2) (i)

Complaint # NJ 4, NJ # 5 Based on interviews, review of medical records (MR), and other facility documentation, it was determined that the facility failed to ensure adequate supervision for 1 of 3 residents, (Resident #1) who displayed exit seeking behavior. On 5/12/2017, Resident #1 verbalized to staff that she was leaving and was trying to leave the building. Additionally, on 5/29/2017, Resident #1 was pacing back and forth to the main door and packing her clothing into plastic bags. On 6/4/2017, at approximately 11:05 a.m., Resident #1 was last seen by her nurse, Licensed Practical Nurse (LPN) #2 in her room watching television. At approximately 11:20 a.m., LPN #2 noticed that Resident #1 was not in her room and began looking for the resident. As LPN #2 was looking for Resident #1, another nurse reported that another resident, who was on the patio outside, saw Resident #1 walking with a doll out the front door. The facility called a code gray to search inside and outside of the facility. LPN #2 asked the receptionist if she saw the resident walking out and the receptionist stated the resident left with family. LPN #2 checked the visitors log, noticed that the family did not sign the resident out, and was told by the family they did not take the resident out of the facility. Resident #1 was found at approximately 11:40 a.m., sitting on the grass by the entrance of a school about 0.5 miles away from the facility by Registered Nurse (RN) #3 and LPN #2. As the staff arrived, an ambulance crew (who was called by a passerby) arrived, and the resident was sent to the emergency room . The facility's failure to ensure the adequate supervision of a resident who was exhibiting exiting seeking behaviors placed Resident #1 and all residents with exit seeking behaviors in an Immediate Jeopardy (IJ) situation. The Administrator, and Director of Nursing (DON) were notified of the IJ on 6/14/2017 at 2:00 p.m. The IJ began on 6/4/2017 when Resident #1 left the facility premises unsupervised, and was lifted on 6/14/2017 when an acceptable plan of correction was received. This deficient practice is evidenced by the following: 1. According to the facility Admission Record Resident #1 was admitted in 2/2017 and had [DIAGNOSES REDACTED]. A Minimum Data Set, (MDS), an assessment tool, dated 5/12/2017, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 6 which indicated severe cognitive impairment. The MDS also revealed the resident required extensive assistance with activities of daily living (ADLS). The surveyor reviewed Resident #1's Care Plans (CP). There was no evidence that Resident #1 had a CP in place regarding the risk of elopement prior to 6/4/2017. A review of Resident #1's MR did not include an elopement evaluation prior to 6/4/2017. A Notice of Discharge from Therapy dated 4/4/2017, indicated the last day of therapy for Resident #1 was 4/10/2017 and recommended interventions including gait training and using a rolling walker for 50 to 75 feet with minimal assist. A Physical Therapy Discharge Summary, dated 4/10/2017, indicated that the resident was discharged to ambulate without an assistive device for up to 100 feet using contact guard. Review of a PN, dated 5/12/2017, at 9:24 a.m. included but was not limited to, Resident was seen walking out from her room towards the exit with few of her clothes (sic) and the toy doll in her hands, she verbalized that she is leaving. Efforts made to redirect her and bring her back to her room but she refused, she then starting kicking the nurse redirecting her still walking towards the exit. After much talking and redirection, she sat on her wheelchair and was taken back to her room with her consent. Review of a PN, dated 5/12/2017, at 9:49 a.m., included but was not limited to, At 9:00 a.m., Pt (resident) became agitated, was trying to leave the building. when (sic) staff tried to bring her back she became very agitated and comb active (combative) .She was taken to (secured) unit and she calmed down. According to a PN, dated 5/29/17 at 11:00 p.m., Resident #1 displays a (sic) agitation pacing back and forth to the main door. Patient (Resident) redirected to room, She then starts to put all of clothing into plastic bags. Ativan given 4:30 p.m. for agitation effective after 30 min. (minutes). Review of a PN dated, 6/4/2017, at 1:24 p.m., revealed, Around 7:30 p.m., (am) patient (resident) was last seen in her room. About 8:30 a.m., patient observed eating breakfast. Around 9:30 a.m., patient (resident) already cleaned sitting in her room, all due meds administered. At about 11:05 a.m. while passing on the hallway attending to another patient (resident), this patient (resident) was observed sitting in her room watching TV. On the way back from the other patient's (resident) room, this patient (resident) was not seen in her room, bathroom and dining room were both checked and she was not there. The nurse in (another unit) came and told writer that one of patient's (resident) informed her that a patient (resident) was seen outside with her doll. Writer went to receptionist and asked her if she saw the patient (resident) going out and she replied yes the patient (resident) went out with family. The writer then call (sic) the patient's (resident) (family member) to inform her that whoever pick her up did not sign her out and she told me that no one was supposed to pick her up. That she will call back. Review of a PN dated 6/4/2017, at 7:20 p.m., revealed, Pt (resident) returned to the facility at 9:40 p.m. accompanied by her family member. Patient (resident) walked in with no apparent distress .Head to toe assessment done, no change in skin integrity observed. Elopement assessment done, secure care (secure bracelet) applied to left ankle. A Facility Reportable Event Record/Report (AAS-45), faxed to the New Jersey Department of Health on 6/5/2017, indicated that on 6/4/2017 at around 11:05 a.m., Resident #1's nurse observed the resident in her room at 11:05 a.m. Approximately five minutes later, the nurse did not see the resident in her bed, and started to look for the resident. At approximately 11:20 a.m., another nurse reported that one of the residents who was outside, reported that she saw Resident #1 with a doll, walking out the front door of the facility. The staff began searching for the resident inside and outside of the facility. At 11:40 a.m., the resident was found outside the facility ground sitting on the grass. No sign of injury was observed upon assessment at that time. As the facility nurse was evaluating the resident, an ambulance crew arrived and transported the resident to the emergency room . The resident returned to the facility. A physical assessment and an elopement assessment were completed, and a secure care bracelet was applied to the resident. Review of the facility's Event Summary included a Summary of Investigation, dated 6/9/2017. Indicated under Root cause/conclusion was that the Resident had [DIAGNOSES REDACTED]. The report further indicated that Resident #1 was alert, verbally responsive, had some confusion, required total care with ADLs, and was wheelchair dependent. The resident exited the facility through the front door possibly following visitors due to her poor cognition and was found out of facility grounds. Additional review of the Event Summary Report included but was not limited to the following corrective actions; Resident was assessed and no apparent injury was observed, ambulance crew came to the location of where the resident was found and the resident transferred to the emergency room for an evaluation. When the resident returned to the facility, physical and elopement assessments were completed, secure care bracelet was applied to the resident's left ankle, and the resident was moved to a secure unit for safety. Review of an Investigative Statement, dated 6/4/17, by RN #3, included but was not limited to the following; At about 11:20 am the supervisor called gray. This nurse went to the look for the patient outside the facility environment on the street. At about 11:40 a.m. I saw the patient sitting on the grass curved (sic). I immediately attended to the patient by telling her that I'm a nurse at Summit Ridge .Patient responded to her name. This nurse began to assess the patient .no facial grimaces or discomfort observed. While still attending to the patient 911 arrived .This nurse asked the patient what happened. Patient replied that she was tired. During an interview with the surveyor on 6/14/2017 at 9:20 a.m., the Administrator stated that on 6/4/2017, Resident #1 walked out the front door of the facility and was found by a staff member off the grounds of the facility, sitting on the grass. The Administrator stated that there was no indication on Resident #1's prior assessments that the resident was an elopement risk. Additionally, the Administrator stated she didn't know if anyone calculated the distance of how far from the facility the resident was located. During an interview with the surveyor on 6/14/2017 at 11:20 a.m., LPN #1 stated Resident #1 did not have exit seeking behavior or express that she wanted to go home. LPN #1 stated that Resident #1 was a one person assist, was unable to ambulate independently, and required the use of a wheelchair. During a subsequent interview with the surveyor at 12:36 p.m., LPN #1 stated that elopement risk assessments are done only if the resident is at risk. LPN #1 further stated that if a resident is exhibiting exit seeking behavior, (I) automatically say they are at risk (for elopement). According to LPN #1, any nurse can do the elopement assessment. The surveyor asked LPN #1 if she was aware of the PN on 5/12/2017 and 5/29/2017. LPN #1 stated she was not in the facility at those times and was unaware of the what happened on those dates. In the presence of the surveyor, LPN #1 read the PN from 5/12/2017 and 5/29/2017, and confirmed the resident displayed exit seeking behaviors. LPN #1 stated an elopement assessment should have been done at that time and the resident should have been given a secure care bracelet because an alarm would have gone off if the resident went to the door. During a subsequent interview with the surveyor at 3:03 p.m., LPN #1 stated that the nurses read the 24 hour report every shift, but she did not recall if she read the 24 report from 5/12/2017 and 5/29/2017. The 24 hour reports for 5/12/2017 and 5/29/2017 were requested by the surveyor. The 24 hour reports that were provided to the surveyor included the PN from 5/12/2017, but did not include a report for Resident #1 on 5/29/2017. During an interview with the surveyor on 6/14/2017 at 11:40 a.m., LPN #2 (who found the resident) stated she was Resident #1's nurse on 6/4/2017. LPN #2 stated Resident #1 was ambulatory and a very fast walker. On 6/4/2017 she saw the resident in her room at around 11:05 a.m. while passing by to attend to another resident. She stated on her way back, she noticed the resident was not in her room, in the bathroom or in the dining room. LPN #2 stated another nurse came to her and told her another resident saw Resident #1 walking with a doll outside. LPN #2 stated the receptionist stated she saw the resident walking out the front door with family. LPN #2 stated she checked the visitors log and didn't see that the resident was signed out, called the family who stated they did not sign the resident out, and reported it to the supervisor when a Code Gray was called. LPN #2 stated she walked with RN #3 outside, down a hill on the road the resident was found. The resident was found sitting on the grass by the entrance to a school. An ambulance came and took the resident to the emergency room . LPN #2 stated that a passerby called an ambulance. LPN #2 stated Resident #1 stated she was exhausted. When Resident #1 returned to the facility, she was given a secure band. During an interview with the surveyor on 6/14/2017 at 12:00 p.m., RN #1 stated she was familiar with Resident #1 who was ambulatory, but needed supervision. On 6/4/2017, she was notified by a nurse that another resident saw Resident #1 walking outside with a doll. RN #1 stated that a code gray was called immediately. The staff checked inside and outside of the facility to locate Resident #1, who was found by a staff nurse outside of the facility. During an interview with the surveyor on 6/14/2017 at 1:25 p.m., RN #2, stated that elopement risk assessments are done when the resident exhibits exit seeking behavior, pacing, states they miss their loved ones, and/or ambulates to exit door. RN #2 stated that after an elopement assessment is done, an elopement CP is initiated/updated, family and physician are contacted, and a secure care bracelet is placed on the resident. RN #2 stated CP's are updated whenever anything is going on with a resident. During an interview with the surveyor on 6/14/2017 at 1:44 p.m., the Assistant Director of Nursing, (ADON), stated that elopement assessments are done when residents verbalize and/or have exiting seeking behavior. The ADON stated that the CP is updated with interventions and the resident is given a secure care bracelet. The surveyor asked the ADON why inservices on elopement were done on 6/7/2017 after Resident #1 eloped. The ADON stated that she reviewed the Resident's PN dated 5/12/2017 and 5/29/2017 and the nurses didn't follow the process. The ADON further stated an elopement assessment should have been completed, a CP should have been initiated, and a secure band should have been applied to the resident when exit seeking behaviors began on 5/12/2017. Additionally, the ADON was not aware of the exact location of where the resident was found on 6/4/2017. During an interview with the surveyor on 6/14/2017 at 2:03 p.m., the surveyor asked the Administrator and the DON for the exact location of where Resident #1 was found. The Administrator and DON stated they did not know, but the nurse who found her would know. During an interview with the surveyor on 6/14/2017 at 4:00 p.m., the DON stated that she was not aware of Resident #1's exit seeking behavior. The DON further stated that when the staff became aware, they should have started the elopement protocol. On 6/14/2017, the surveyor drove to the location where LPN #2 stated the resident was found. The calculated distance was 0.5 miles from the facility per the state vehicle odometer. Review of the facility's policy titled, OPS111 Elopement of Patient dated, 6/1/96, revised on 5/15/14, included but was not limited to: Policy: Patients will be evaluated for elopement risk upon admission, re-admission, quarterly, and with a change in condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. 1. Assessment/Evaluation 1.1 Identify patient's elopement risk by reviewing the following upon admission, re-admission, quarterly, or with a significant change in conditions as defined by RAI Manual Criteria. 1.1.1 Electronic Medical Record Systems - Nursing Assessment. 1.1.2 Non - electronic Medical Records Systems. 1.2 Complete the Elopement Evaluation (both electronic and non-electronic) 1.2.1 If a patient exhibits signs of elopement risk between routine assessments/evaluation . 1.3 For patients identified as a risk, an interdisciplinary elopement prevention care plan will be developed with family and patient participation. 1.3.1 Individual risk factors and patterns will be identified and addressed within the care plan. 1.3.2 Obtain current photograph of patient. 1.3.3 Complete the Elopement Risk Identification form for all patients at risk of elopement and place in a binder that is easily accessible to staff. 2. Witnessed elopement: 2.1 Staff witnessing a confused patient or an identified elopement risk patient attempting to leave the Center will intervene as appropriate to redirect the patient to a safe area and prevent elopement. 2.2 If the patient cannot be redirected, alert other staff members to notify the supervisor and stay with the patient until he/she is safely returned to the center. Review of the facility's policy titled, OP416 Person-Centered Care Plan, dated 11/23/16, included but was not limited to: Policy: The Center must develop and implement a baseline person-centered care plan within 48 hours for each patient that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. 2. A comprehensive person-centered care plan must be developed for each patient and must describe the following: 4. The PointClickCare (PCC) care plan library is used to develop the patient's care plan. 4.1 The care plan must be customized to each individual patient's preferences and needs. 5. Care plans will be: 5.1 Communicated to appropriate staff, patient, HCDM (Health Care Decision Maker), family. 5.2 Reviewed and revised a minimum of quarterly and as needed to reflect the response to care and changing needs and goals . 5.3 Documented on the Care Plan Evaluation Note. The IJ to the resident's health and well being began on 6/4/2017 at approximately 11:20 a.m., when Resident #1 left the facility premises unsupervised and was lifted on 6/14/2017 at 3:58 p.m., when an acceptable Plan of Correction (P(NAME)) was implemented as follows: 1. Upon return from theER on [DATE], resident was assessed for elopement; secure bracelet was applied to the left ankle per protocol, placed in the secured unit for recreational activities. Her room was changed to the secured unit on 6/6/17. No other resident was found to be affected. 2. All resident are at risk to be affected by this practice. 3. Staff were re in-serviced, and in-service will be maintained quarterly and as needed on the following: 1. 6/14/17- Shift to shift Communication of change in status/condition (behavioral, medical, or any incident) 2. 6/7-6/12/17- Identification of Behavioral signs of elopement 3. 6/7-6/12- Policy and procedure on elopement 4. 6/7-6/12/17- Elopement assessment protocol 5. 6/7-6/12/17- Care plan for elopement All residents in the building were assessed for elopement on 6/12/17. A sign was placed by the receptionist are (area) for all visitor to consult the receptionist before assisting patients/residents outside the facility (sic). 4. Unit managers/designee will audit all new admissions weekly and as needed to ensure that elopement assessments and care plans are completed accordingly and report to ADON/Designee. ADON/Designee will review the reports and follow up biweekly x 3 months All findings of audits will be reviewed during monthly and quarterly CQI meeting. NJAC 8:39-27.1(a)