Every finding on record at Complete Care at West Caldwell LLC

Based on interviews and review of pertinent facility documents on [DATE], it was determined that the facility failed to complete and thoroughly investigate the fall incident of a cognitively impaired resident (Resident #5) to rule out abuse and neglect. On [DATE] the resident was found unresponsive on the floor next to their bed with their head in the trash bin lined with clear plastic bag. The facility called 911 and police came. The resident was pronounced dead by EMS [emergency medical services] at bedside. This deficient practice was identified for 1 of 5 residents reviewed and was evidenced by the following:The surveyor reviewed the medical record for Resident #5. A review of the facility's Reportable Event Record (RER), a document submitted by the facility to the New Jersey Department of Health (NJDOH), with an event date of [DATE] and an event time of 12:57 AM was reported by the facility's Previous Administrator. Under Type of Incident reported was Unexpected Death. The Narrative indicated that at approximately 1:00 AM, Certified Nursing Assistant (CNA) #1 was assisting another patient when they heard a sound coming from Resident #5's room. When CNA entered the room, Resident #5 was on the floor next to their bed. Upon checking, Resident #5 was observed to be non-responsive. CNA immediately notified the nurse and registered nurse (RN) Supervisor. RN Supervisor called 911 while nurses and CNAs retrieved the AED and Code cart. As soon as the nurses began implementing emergency response measures. When the police arrived, approximately 2 minutes later, they took the lead on emergency response. The facility did not submit an Investigation, Summary, and Conclusion (ISC) to the NJDOH, as requested by the department. A review of the admission Record (AR) face sheet (an admission summary), revealed that Resident #5 was admitted to the facility with diagnoses which included but were not limited to: generalized idiopathic epilepsy and epileptic syndromes (sudden uncontrollable jerking, stiffening movements caused by various factors including genetic, structural, metabolic, and autoimmune factors), developmental disorder of scholastic skills, generalized osteoarthritis (degeneration of joint cartilage and the underlying bone affecting multiple joints, causing widespread pain, stiffness, and swelling), muscle weakness, and difficulty walking. A review of the Minimum Data Set (MDS), an assessment tool dated [DATE], indicated Resident #5 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating Resident #5 had severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs)).A review of Resident #5's individual comprehensive care plan (ICCP) included a focus area dated [DATE] that the resident had a seizure disorder r/t [related to] Epilepsy. Interventions included but were not limited to give medications as ordered, monitor labs and report any sub therapeutic or toxic results to MD [medical doctor], post seizure treatment, seizure documentation, and seizure precautions. The IICP as included a [DATE] that the resident was moderate risk for falls r/t gait/balance problems, poor communication/comprehension, seizure disorder and history of falls. Interventions included but were not limited to anticipate and meet the resident's needs, be sure the resident's call light was within reach, and the resident needs a safe environment (even floors, free from spills or clutter, adequate light, working and reachable call light, bed in low position at night, side rails as ordered, personal items within reach).On [DATE] at 12:16 PM, the surveyor requested for the facility's ISC, investigation report and documents for the [DATE] incident involving Resident #5. The LNHA provided the surveyor with Resident #5's investigation documents (ID). The surveyor was not able to find the ISC in the investigation documents. The LNHA stated that she started to work as the LNHA in the facility in June of 2025 and she was not aware of or if an ISC was made and submitted by the previous administrator who resigned from the facility before June of 2025. The surveyor reviewed the facility's ID. There was no facility ISC nor staff statements in the documents received by the surveyor. Statements received by the surveyor were VWSs taken by the local police.On [DATE] at 1:16 PM, the LNHA provided the surveyor of a document titled, Summary of Investigation (SOI). The SOI indicated under Issue/Concern: On [DATE] at approximately 120 [1:20 am] [Resident #5] was found lying next to [their] bed with a garbage pail at the top of her head. Under Action/Intervention: Staff immediately began CPR [cardiopulmonary resuscitation] and called 911.Under Conclusion/Plan: There is no evidence of abuse or neglect .Team has concluded .It is most likely the resident [Resident #5] suffered a fatal seizure and rolled off the bed onto the floor and [their] head hit the bedside garbage pail.A review of the facility's Abuse, Neglect, and Exploitation with a Reviewed/Revised date of [DATE] revealed under Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that .b. Establish policies and procedures to investigate any such allegations. Under Investigation of Alleged Abuse, Neglect, and Exploitation: B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation .4. Identifying and interviewing all involved persons, witnesses, and others who might have knowledge of the allegations; .6. Providing complete and thorough documentation of the investigation.NJAC 8:39-4.1(a)5

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that there was a Licensed Nursing Home Administrator (LNHA) who was licensed in New Jersey (NJ), who was actively involved in daily oversight to ensure all policies and procedures were implemented and followed in the facility to ensure the residents' physical and psychosocial care needs were met. Refer to F 837 F The evidence was as follows: On 3/17/25 at 8:28 AM, the surveyor observed a posted chain of command on a bulletin board within the facility's entrance that had the Acting Administrator (AA) at the top of list with the letters LNHA and MPA (Master of Public Administration) next to his name. On 3/17/25 at 9:10 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the facility's administrator was the AA, and that he was stuck in traffic, but on his way to the facility. At that time, the surveyor requested the AA's nursing home administrator's license, and the DON stated he would get it from the AA when he arrived at the facility. On 3/17/25 at 9:40 AM, the surveyor interviewed the AA, who stated that he was the administrator for the facility. The surveyor requested a copy of his license, and the AA stated that he was licensed in the state of [name redacted] as an administrator. The AA then stated that he was the administrator for this facility since August of 2024. The AA stated that there was another staff member, who was the LNHA, LNHA #1, who was licensed in NJ and that the facility contacted him as needed, up to daily and he came here every now and then. The AA stated that he was waiting on reciprocity from the state of NJ and the facility was being ran by LNHA #1. The surveyor asked when the last time that LNHA #1 was here in the facility, and the AA stated that he was not sure when LNHA #1 was last here, that LNHA #1 was currently on vacation. On 3/17/25 at 9:45 AM, the surveyor interviewed RDO #1, who stated that the administrator was the AA, and that the AA was waiting on reciprocity from NJ. RDO #1 then stated that LNHA #1, who was licensed in NJ, was the person that the facility contacted if needed for administrative purposes. RDO #1 stated that he was not sure the last time that LNHA #1 was at the facility. On 3/17/25 at 9:50 AM, the surveyor interviewed the Receptionist, who stated that the administrator was the AA. The Receptionist then stated that the AA's name was posted at the entrance to the facility. On 3/17/25 at 9:55 AM, the surveyor interviewed the Registered Nurse (RN #1), who stated that the administrator was the AA. RN #1 continued that there used to be a different administrator, LNHA #1, who quit many months ago and she had not seen him since that time. RN #1 stated that she had worked here for over [AGE] years. On 3/17/25 at 9:57 AM, the surveyor interviewed the Maintenance Employee, who stated that he had worked at the facility for two months and that the administrator was the AA. A review of a letter from Human Resources, dated 12/17/24, to the New Jersey Department of Health, revealed that [AA] had the job title of the administrator with a start date of 8/12/24, and the work schedule was 40 hours per week. A review of the Quality Assurance Performance Improvement (QAPI) committee, which was from the 3rd quarter (July 2024 to September 2024) and the 4th quarter (October 2024 to January 2025), revealed that the AA signed that he had attended the QAPI meetings as the LNHA. A review of the Administrator Job Offer signed by the AA and the Regional Director of Operations (RDO # 2) on 8/8/24, revealed: The offer [to the AA] is contingent upon successful completion of . maintenance of the appropriate licenses. A review of the Administrator Job Description signed by the AA on 8/19/24, revealed: Purpose of the job position is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities, to follow all facility policies and apply them to all employees, to ensure the highest degree of quality care is provided to our residents at all times. Education and Qualifications of Administrator: Must be a NJ Nursing Home Administrator. NJAC 8:39-9.2(a)2

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the Governing Body (GB) appointed a Licensed Nursing Home Administrator (LNHA) who was actively licensed in the state of New Jersey (NJ) to implement the facility's policies and procedures to ensure the residents' physical and psychosocial care needs were met. Refer to F 835 F The evidence was as follows: On 3/17/25 at 8:28 AM, the surveyor observed a posting of the chain of command in the facility's entrance. The Acting Administrator (AA) was listed at the top of the list with the letters LNHA and MPA (Master of Public Administration) next to his name. On 3/17/25 at 9:10 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the facility's administrator was the AA, and that he was stuck in traffic, but he was on the way to the facility. At that time, the surveyor requested the AA's nursing home administrator's license, and the DON said that he would get it from the AA when he arrived at the facility. On 3/17/25 at 9:40 AM, the surveyor interviewed the AA, who stated that he was the administrator for the facility. When the surveyor requested a copy of his license, the AA stated that he was licensed in the state of [name redacted] as a nursing home Administrator. Then the AA stated that he was the administrator for this facility since August of 2024. The AA stated that there was another staff member, who was the LNHA (LNHA #1), who was licensed in NJ and that the facility contacted him as needed, up to daily and he came here every now and then. The AA stated that he was in reciprocity for the state of NJ and things were ran by LNHA #1. The surveyor asked when the last time that LNHA #1 was here in the facility, and the AA stated that he was not sure when LNHA #1 was last here, that LNHA #1 was currently on vacation. On 3/17/25 at 9:45 AM, the surveyor interviewed the Regional Director of Operations (RDO #1), who stated that the administrator was the AA, and that he was waiting on reciprocity from NJ. RDO #1 then stated that LNHA #1 had a NJ administrator's license, and he was the person that the facility contacted if needed for administrative purposes. RDO # 1 stated he was not sure the last time that LNHA #1 was at the facility. On 3/17/25 at 9:50 AM, the surveyor interviewed the receptionist, who stated that the administrator was the AA. The receptionist then stated that his name was posted at the entrance to the facility. On 3/17/25 at 9:55 AM, the surveyor interviewed the Registered Nurse (RN #1), who stated that the administrator was the AA. RN #1 stated that there used to be a different administrator, LNHA #1, who quit many months ago and she had not seen him since that time. RN #1 stated that she had worked here for over [AGE] years. On 3/17/25 at 9:57 AM, the surveyor interviewed a maintenance employee, who stated that he had worked at the facility for two months, and the AA was the administrator. A review of the Administrator Job Offer, signed by the AA and RDO # 2 on 8/8/24, revealed: The offer [to the AA] is contingent upon successful completion of . maintenance of the appropriate licenses. A review of a letter from Human Resources dated 12/17/24, sent to the New Jersey Department of Health (NJDOH) revealed that the AA had the job title of the administrator with a start date of 8/12/24, and the work schedule was 40 hours per week. A review of the Quality Assurance Performance Improvement (QAPI) committee, which was from the 3rd quarter (July 2024 to September 2024) and the 4th quarter (October 2024 to January 2025), revealed that the AA signed that he had attended the QAPI meetings as the LNHA. A review of the Facility Assessments (FA) dated 7/10/24 and 11/15/24, Guidelines for Conducting the Facility Assessment, indicated that to ensure the required thoroughness of the assessment, the GB should include at a minimum the administrator, a GB representative, the Medical Director and the DON. The FA indicated that the GB consisted of RDO #2 and RDO #3, Owner # 1, Owner # 2, and the Medical Director. On 3/19/25 at 1:30 PM, the surveyor interviewed RDO #3, who stated that RDO #2 was involved with the hiring process of the AA. RDO #3 stated that she was involved with the training of the AA in his position as the administrator for the facility. On 3/20/25 at 11:00 AM, the surveyor received and reviewed the August 2024 through March 2025, calendars for the weekly meetings for oversight of the AA. The calendars indicated that RDO #3 held meetings every Tuesday at 10:00 AM with the facility. On 3/20/25 at 11:30 AM, the survey team was unable to interview the Medical Director who was out of the country. On 3/20/25 at 12:30 PM, the surveyor interviewed the Director of Clinical Services (DCS), who stated that RDO #2 and RDO #3 provided oversight to the AA while he was working at the facility without a NJ nursing home administrator's license. On 3/20/25 at 1:25 PM, the surveyor interviewed Owner #1, who stated that he was aware that the AA did not have a NJ nursing home administrator's license. Owner #1 stated that he thought the previous LNHA was supposed to remain employed with the facility to oversee the AA until he received reciprocity. On 3/20/25 at 2:10 PM, the surveyor reviewed LNHA #1's employee payroll record which revealed that the last date he worked was 8/12/24. A review of the Administrator Job Description signed by the AA on 8/19/24, revealed: Purpose of the job position is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities; to follow all facility policies and apply them to all employees; to ensure the highest degree of quality care is provided to our residents at all times; Education and Qualifications of Administrator: Must be a NJ Nursing Home Administrator. A review of the facility's Governing Body policy dated 1/1/23, included that the GB is legally responsible for establishing and implementing policies regarding the management and operation of the facility. The GB will appoint an administrator who is licensed by the state where required; responsible for management of the facility; and reports to and is accountable to the GB. The GB will have a process in place by which the administrator reports to the GB; a method of communication between the administrator and the GB; how the administrator is held accountable and reports information to the facility's management and operation; and how the administrator and the GB are involved with the facility wide assessment. NJAC 8:39-9.4(a)

NJ 163118 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to adjust medication administration times to accommodate for scheduled dialysis times. This deficient practice was identified for 1 of 2 resident (Resident #341) reviewed for dialysis and was evidenced by the following: On 3/18/25 at 12:49 PM, the surveyor reviewed the closed records for Resident #341. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; end stage renal (kidney) disease, chronic kidney diseases and diabetes mellitus with diabetic polyneuropathy (multiple nerves throughout the body become damaged or dysfunctional). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/13/23, included the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received dialysis while a resident at the facility. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 4/26/23, that the resident had altered health maintenance, unstable blood sugars. The ICCP interventions included Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, dated 4/26/23. The ICCP did not include any interventions to schedule medications around the resident's scheduled dialysis times. A review of the Order Summary Report (OSR), dated as of 8/16/23, included the following physician orders (PO): A PO, dated 4/25/23, for dialysis on Mondays, Wednesdays, and Fridays with a chair time of 2:00 PM and a pickup time of 9:00 AM. A review of the August 2023, electronic Medication Administration Record (eMAR) included the following POs: -Novolog Flex Pen subcutaneous solution pen injector 100 unit/ml, inject 12 units subcutaneously in the evening for diabetes mellitus, to be given 15 minutes before dinner. The order was initiated on 7/11/23 and ended on 8/8/23. The Novolog was scheduled to be administered daily at 4:30 PM. Further review revealed the following: On Wednesday, 8/2/23, the administration was marked x and charted with a code of 9 (sleeping). On Friday, 8/4/23, the administration was marked x and charted with a code of 9 (sleeping). On Monday, 8/7/23, the administration was marked x and charted with a code of 9 (sleeping). -Novolog Flex Pen subcutaneous solution pen injector 100 unit/ml, inject 14 units subcutaneously in the evening for diabetes mellitus, to be given 15 minutes before dinner. The order was initiated on 8/8/23 and ended on 9/2/23. The Novolog was scheduled to be administered daily at 4:30 PM. Further review revealed the following: On Wednesday, 8/9/23, the administration was marked x and charted with a code of 9 (sleeping). On Friday, 8/11/23, reflected a charting blank. On Monday, 8/14/23, the administration was marked x and charted with a code of 9 (sleeping). On Wednesday, 8/16/23, the administration was marked administered. A review of the Medication Administration Audit Report (MAAR) for 8/16/23, reflected the Novolog was administered at 7:43 PM. On Friday, 8/18/23, the administration was marked x and charted with a code of 9 (sleeping). On Monday, 8/21/23, the administration was marked x and charted with a code of 9 (sleeping). On Wednesday, 8/23/23, the administration was marked administered. A review of the MAAR for 8/23/23, reflected the Novolog was administered at 9:33 PM. On Wednesday, 8/25/23, the administration was marked administered. A review of the MAAR for 8/25/23, reflected the Novolog was administered at 9:17 PM. On Wednesday, 8/28/23, the administration was marked administered. A review of the MAAR for 8/28/23, reflected the Novolog was administered at 8:25 PM. On Friday, 8/30/23, the administration was marked administered. A review of the MAAR for 8/30/23, reflected the Novolog was administered at 8:53 PM. A review of the Resident 341's lab results did not reflect the A1C was checked (hemoglobin A1C; a laboratory (lab) blood test that measures the average amount of sugar in the blood over the past three months) while in the facility. The closed record provided by the facility did not include A1C results from the dialysis center. A review of the Nurse's Progress Note on 9/2/23, reflected Resident #341 was discharged to home. On 3/20/25 at 2:16 PM, during a meeting with the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Administrator in Training (AIT) and the [NAME] President of Clinical (VPC), the surveyor discussed the concern regarding Resident #341's Novolog that was scheduled for administration everyday at 4:30 PM, while the resident was at dialysis center for treatment and the concern that the A1C for the resident was not reflected in the resident's medical record. On 3/21/25 at 11:01 AM, during a meeting with the surveyors, the DON, the LNHA, and the AIT, the VPC stated that facility conducted mock survey on 1/7/25, and identified that medication administration times and hemodialysis times were not consistent with the facility's policy and procedure. The VPC also stated that the hemodialysis center (HDC) had taken the resident's labs monthly. The process was that the HDC obtained labs, and the facility had the ability to request additional labs to be drawn on the next lab draw. A review of the provided facility policy for Hemodialysis, dated/revised 1/25, included, the licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as dialysis communication form or other form, to include but not limit itself to timely medication administration (initiated, held, or discontinued) by the nursing home and/or dialysis facility; physician/treatment orders, laboratory values and vital signs . NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 1 of 5 residents, Residents #4, reviewed for immunization status. This deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 10/26/24, included the following. The CDC recommended administration of Pneumococcal conjugate vaccine (PCV20 or PCV21) at least 1 year for all adults [AGE] years or older who have received PCV 13 only at any age. On 03/17/25 at 9:58 AM, the surveyor observed Resident #4 was in bed, the head of the bed was elevated, was administered oxygen via nasal cannula and the concentrator was set to 3 liter per minute. Resident #4 was alert, and conversant. The surveyor reviewed Resident #4's medical record. The Admission Record (AR, admission summary) reflected that Resident #4 was admitted to the facility with medical diagnoses which included but were not limited to: chronic obstructive pulmonary disease (COPD; constriction of the airways making it difficult or uncomfortable to breathe), and acute respiratory failure with hypoxia (sudden onset of an inability to breath resulting in decreased levels of oxygen in the blood and to body tissue). Resident #4's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 2/4/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out 15 which indicated the resident's cognition was moderately impaired. Further review of the qMDS dated [DATE], under section O0300 A. Is the resident's Pneumococcal vaccine (PV) up to date? The response was marked 1, which reflected Yes. A review of the electronic Medical Record (eMR) under Immunization reflected Resident #4, received Prevnar 13 on 9/22/21. The paper chart did not reflect declination of Pneumococcal vaccine. On 3/20/25 at 2:16 PM, during a meeting with the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Administrator in Training (AIT) and the [NAME] President of Clinical (VPC), the surveyor discussed the concern regarding Resident #4 whose qMDS reflected that the PV was current. On 3/21/25 at 11:01 AM, during a meeting with the surveyors, the DON, the LNHA, and the AIT, the VPC stated that the declination of the PV was provided to another surveyor, and that the qMDS was modified after surveyor inquiry. A review of the modification of MDS reflected the record was modified on 3/20/25 at 5:27 PM. No further information was provided. NJAC 8:39-33.2 (d)

Based on observation, interview, and record review it was determined that the facility failed to ensure a pain management regimen was followed in accordance with physician orders. This deficient practice was identified in 1 of 3 residents reviewed for pain (Resident #2). This deficient practice was evidenced by the following: On 3/17/25 at 9:43 AM, during the initial tour of the facility Resident was observed in bed covered with a blanket. The resident stated that their teeth hurt and may have received pain medication at 6:00 AM that morning. The surveyor reviewed Resident #2's Admission Record (an admission summary) which showed that Resident #2 was admitted to the facility with diagnoses which included but were not limited to: non pressure chronic ulcer of both lower leg ( persistent open wounds on both legs that are a result from prolonged venous insufficiency (condition wherein the veins cant manage the blood flow) and peripheral vascular disease ( a condition that affects the blood vessels causing narrowing, blockage or spasms). A review of the quarterly Minimum Data Set (qMDS) dated [DATE], indicated the resident had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicated the resident has a severely impaired cognition. Review of Section J, titled Health Conditions, revealed that the resident had a pain assessment completed. It showed that the resident had an as needed (PRN) pain medication, had pain occasionally, had pain that interrupted sleep occasionally, and had pain that had interfered on day-to-day activities occasionally. Pain intensity for the five days prior to the assessment was eight, meaning it was severe pain on a scale of one (least severe) to ten (most severe). A review of Resident #2's Order Summary Report for March 2025, reflected an order for Oxycodone -Acetaminophen 5 milligram (mg)/325 mg (Percocet; a narcotic pain reliever). Give one (1) tablet every 6 hours as needed for pain scale of 7 to 10. The order was started on 11/13/24. A review of the Resident #2's electronic Medication Administration Record for March 2025, revealed the following: Resident #2 received Percocet 5/325 mg on 3/1/25 for pain level of three at 3:51 PM. Resident #2 received Percocet 5/325 mg on 3/3/25 for pain level of six at 8:53 PM. Resident #2 received Percocet 5/325 mg on 3/7/25 for pain level of three at 2:16 AM. Resident #2 received Percocet 5/325 mg on 3/16/25 for pain level of five at 8:31 AM. On 3/21/25 at 11:40 AM, during a meeting with two surveyors, the [NAME] President of Clinical (VPC) and the Infection Preventionist (IP), the surveyor discussed the concern regarding Resident #2 who had a severely impaired cognition, the administered Percocet for pain scale below 7 against the physician's order and the appropriateness of the pain scale interview for Resident #2. On 3/21/25 at 12:35 PM, during a follow-up meeting with a surveyor, the VPC acknowledged and confirmed the administration of Percocet was incorrect and that the nurses would be educated. A review of the provided facility policy, Administering Medications, dated/revised 10/2022, included under policy statement that medications shall be administered in a safe, timely manner, and as prescribed. NJAC-8:39-27.1 (a)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to ensure the Consultant Pharmacist identified a drug, Levothyroxine for hypothyroidism was spaced 4 hours apart from Calcium Carbonate, in accordance with manufacturer's specifications. This deficient practice was identified for 1 of 5 residents (Resident #4) reviewed for unnecessary medications and was evidenced by the following: Reference: According to the manufacturer's specifications for Levoxyl (Levothyroxine) section 7. Drug Interactions, under table 2. Calcium Carbonate may form an insoluble chelate with levothyroxine, . Administer Levoxyl at least 4 hours apart from these agents. Reference: According to the manufacturer's specifications for Synthroid (Levothyroxine) section 7. Drug Interactions, under table 2. Calcium Carbonate concurrent use may reduce efficacy of Synthroid by binding and delayinng or preventing absorption, potentially resulting in hypothyroidism . Administer Synthroid at least 4 hours apart from these agents. The Admission Record (AR, admission summary) reflected that Resident #4 was admitted to the facility with medical diagnoses which included but were not limited to: chronic obstructive pulmonary disease (COPD; constriction of the airways making it difficult or uncomfortable to breathe), and acute respiratory failure with hypoxia (sudden onset of an inability to breath resulting in decreased levels of oxygen in the blood and to body tissue). Review of Resident #4's March 2025 electronic Medication Administrator Record included the following orders: Levothyroxine 150 microgram (mcg), give 1 tablet one time a day for low thyroid hormone. The order date was on 2/17/24 and the administration time was scheduled for 6:00 AM. Calcium Carbonate 600 mg. give 1 tablet by mouth two times a day for supplement. Give with meals and within 30 minutes of meals. The order date was on 11/19/24 and the administration time was scheduled for 9:00 AM and 5:00 PM. Review of Resident #4's February 2025 electronic Medication Administrator Record included the following orders: Levothyroxine 175 mcg, give 1 tablet one time a day for low thyroid hormone. The order date was on 12/16/24 and the administration time was scheduled for 6:00 AM until 2/17/25. On 2/18/25, the administration time was changed to 9:00 AM, a charting omission on 2/19/25 and was returned to 6:00 AM on 2/22/25. Calcium Carbonate 600 mg. give 1 tablet by mouth two times a day for supplement. Give with meals and within 30 minutes of meals. The order date was on 11/19/24 and the administration time was scheduled for 9:00 AM and 5:00 PM. A review of the Consultant Pharmacist's Summary Report from 11/01/2024 through 03/18/2024, did not include a recommendation to separate the Calcium Carbonate and Levothyroxine at least 4 hours apart in accordance with manufacturer's specifications. On 3/20/25 at 10:46 AM, during an interview with the surveyor, the Consultant Pharmacist (CP) stated that the resident had orders for Calcium, Ferrous Sulfate and Levothyroxine which made the spacing of administration complicated. At that time, the CP did not make the recommendation based on his professional opinion he was satisfied with the spacing of medication and that the resident was spaced three (3) to four (4) hours. The dosing of Levothyroxine was reduced from 175 mcg to 150 mcg in February 2025 and did not show worsening. A review of the facility provided, Resident #4's Thyroid panel collected on 1/22/25, reflected the thyroid stimulating hormone was 0.11 and was below normal limits (reference range 0.3 to 4.2), the Free T4 was 1.9 and was higher than normal limits (reference range 0.9 to 1.7). A review of the facility provided, Resident #4's Thyroid panel collected on 3/14/25, reflected the thyroid stimulating hormone was 1.88 and within normal limits (reference range 0.3 to 4.2), the Free T4 was 1.2 and within normal limits (reference range 0.9 to 1.7). On 3/20/25 at 2:16 PM, during a meeting with the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Administrator in Training (AIT) and the [NAME] President of Clinical (VPC), the surveyor discussed the concern regarding the Medication Regimen Review for Resident #4, wherein the spacing of the Calcium Carbonate and Levothyroxine was not identified as an irregularity by the CP and was not in accordance with the manufacturer's specification. A review of the facility provided documentation, Artificial Intelligence (AI) overview from the CP reflected under timing reflected that it was recommended to take Synthroid at least 3 to 4 hours before or after consuming calcium supplements or calcium-rich foods. The 3 hours spacing was not reflected on the manufacturer's specifications. A review of the facility provided policy for Medication Regiment Review (MRR), dated/revised November 2023 included that the MRR involved a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities . NJAC 8:39-29.3

Based on observations, interviews, document review, and facility policy review, it was determined that the facility failed to ensure nail care was provided to 1 (Resident # 13) of 5 residents reviewed for activities of daily living. Findings included: Review of facility policy titled, Activities of Daily Living (ADL) Policy reviewed and approved August 2022 revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the Certified Nursing Assistant job duties revised May 2022, revealed a Certified Nursing Assistant (CNA) 3. Assists with activities of daily living and incontinence care. 4. Bathes the resident in bed, tub or shower, combs hair, cleans and cuts fingernails and give shampoos. A review of an Admission Record indicated the facility admitted Resident #13 with a diagnosis of legal blindness. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had a Brief Interview of Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Per the MDS, Resident #13 was totally dependent on staff for personal hygiene. On 03/27/2023 at 1:13 PM, Resident #13 was observed to have long, dirty fingernails. Resident #13 stated they had long nails and did not like long nails. On 03/28/2023 at 2:13 PM, Resident #13's fingernails were observed to be long and dirty. A review of the facility's 2nd Floor LTC [long term care] Shower Schedule revealed Resident #13 was scheduled to have a shower on Tuesdays and Fridays on the 7:00 AM to 3:00 PM shift. On 03/28/2023 at 3:48 PM, an observation revealed Resident #13 had a bed bath; however, the resident's fingernails were not cleaned or trimmed. On 03/29/2023 at 9:50 AM, Resident #13's fingernails were observed to be long and dirty. During an interview on 03/29/2023 at 10:00 AM, Licensed Practical Nurse (LPN) #1 stated no staff had reported that Resident #13 refused to allow staff to trim or clean their fingernails. She stated staff should always try to clean and trim residents' fingernails and if there were any issues, the staff should report them to the nurse. During an interview on 03/29/2023 at 10:25 AM, CNA #6 stated she gave Resident #13 a bed bath earlier that day and should have cleaned and trimmed the resident's fingernails. She stated that cleaning and trimming a resident's nails was part of the residents ADL care and should have been completed. CNA #6 stated if staff were unable to complete ADL care, it should be reported to the nurse. During an interview on 03/29/2023 at 11:15 AM, CNA #7 stated when residents were assisted with a bath or shower, staff were supposed to clean and trim the resident's fingernails, if needed. During an interview on 03/29/2023 at 11:24 AM, CNA # 9 stated when residents received a bath or shower, staff were supposed to clean and trim the resident's fingernails. CNA #9 stated Resident #13's fingernails should have been cleaned and trimmed. During an interview on 03/29/2023 at 3:43 PM, the Director of Nursing (DON) stated she expected staff to provide ADL care for all residents. The DON said ADL care included cleaning and trimming a resident's nails. According to the DON. CNAs or nurses could trim residents' fingernails. The DON further stated if a resident refused nail care, it should be reported to the supervisor. During an interview on 03/30/2023 at 11:07 AM, the Administrator stated he expected staff to perform their job duties. The Administrator stated he expected staff to make sure the residents had good hygiene and clean and trim the residents' fingernails. New Jersey Administrative Code S 8:39-27.2 (g)

C #: NJ 519 Based on interviews, review of medical records, and other pertinent facility documents on 7/28/22 and 7/29/22, it was determined that the facility failed to notify the Resident's Representative (RR) about the Resident's significant change in condition and transfer to the Hospital. The deficient practice was identified for 1 of 3 residents (Resident #4) reviewed for family notification and was evidenced by the following: According to the medical record, Resident #4 was admitted to the facility on [DATE] and discharged to the hospital on 12/30/21. The Resident was readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment tool dated 12/29/21, showed that Resident #4's cognitive status was intact and required extensive assistance from staff for Activities of Daily Living (ADL) The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Notes (PN) and Transfer Summary (TS), dated 12/30/21, revealed that Resident #4 was noted with low blood pressure and lethargy and subsequently transferred to the Hospital by 911 emergency ambulance as ordered by the primary physician. However, there was no documented evidence in the PN or TS that the RR was notified about the Resident's significant change in condition or transfer to the Hospital. The Assistant Director of Nursing (ADON) was interviewed on 7/29/22 at 11:50 am, she stated that the family is informed in the event of a significant change in Resident's condition or when a Resident is transferred to the Hospital. The nurses are responsible for notifying the RR and this notification is documented in the Resident's paper chart or Electronic Medical Record (EMR). The Registered Nurse (RN #1, assigned nurse to Resident #4) was interviewed on 7/29/22 at 12:23 pm, she stated that she did not notify the RR on 12/30/21 when Resident #4 had a significant change in condition which led to emergency hospitalization . The Licensed Practical Nurse (LPN #1, nurse who assisted RN #1) was interviewed on 7/29/22 at 12:33 pm, she stated that she completed the TS for Resident #4 on 12/30/21. The LPN stated she could not recall if she notified the RR about the the Resident's significant change in condition and the transfer to the Hospital on 12/30/21. She acknowledged that there was no written documentation in the TS that the RR was notified. Resident #4 was interviewed on 7/29/22 at 1:35 pm, who stated I would like them (the facility) to notify my family about my health condition. The Resident explained that the RR is the only family he/she has and only visits occasionally. Therefore, the RR should be notified about his/her health condition. The Director of Nursing (DON) was interviewed on 7/29/22 at 1:40 pm, she stated she expects the nurses to notify the RR for changes in the Resident's condition and document the notification in the paper chart or EMR as stated in their policy. The DON acknowledged that there was no documented evidence in the chart or EMR that the RR was notified about the Resident's change in condition or transfer to the hospital. Review of policy titled Change in Condition Policy, revised 8/2021, indicated under Procedure 1. The physician, resident and/or responsible party will be promptly notified in the event of a significant change in condition or plan of care. 3. This notification shall be documented in the clinical record by the appropriate personnel . NJAC 8:39-4.1 (a)31(i)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that hand hygiene was performed to prevent the spread of infection. This deficient practice was identified for 1 (occupational therapist) of 10 facility staff members reviewed for hand hygiene. This deficient practice was evidenced by the following: On 10/22/20 at 10:58 AM, the surveyor observed an occupational therapist exiting room # 231 which was a cohort room to observe for symptoms of COVID-19. The occupational therapist did not perform hand hygiene when she exited the room or when she exited the observation unit for new or re-admissions. On that same day, the surveyor interviewed the occupational therapist who stated I felt I was not in contact with the resident. She confirmed she had training on infection control practices related to COVID-19 On 10/29/20 at 11:40 AM, the surveyor interviewed the occupational therapist who stated, I should have washed my hands with soap and water before leaving the room. A review of the hand hygiene revised 1/1/11 policy provided by the Administrator indicated that all personnel working in the facility are required to wash their hands after resident contact .The organization follows CDC (Center for Disease Control) hand hygiene guidelines. NJAC 8:39-19.4 (n)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medication were administered according to physician orders [REDACTED].#33) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statues Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/27/20 at 8:55 AM, during the medication observation pass, the surveyor observed a Licensed Practical Nurse (LPN) taking Resident #33's blood pressure which was 129/70. The surveyor then observed the LPN administer Losartan 50 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME]-150 mg, [MEDICATION NAME] 12.5 mg, [MEDICATION NAME] 25 mg, Vitamin C 500 mg and [MEDICATION NAME] 40 mg to Resident #33. The surveyor reviewed Resident #33's medical record. The resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the October 2020 physician's orders [REDACTED]. The order also noted to hold the medication for Systolic Blood Pressure less than 130. The surveyor also reviewed the October 2020 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The surveyor interviewed the LPN who stated that she should have held Resident #33's Losartan because the resident's systolic blood pressure was less than 130. On 10/27/20 at 1:30 PM, the surveyor discussed the above concern with the Director of Nursing and the Administrator. No additional information was provided. A review of the facility's policy titled Medication and Treatment Record Administration under #6 g. Check medication container label against transcribed medication order written on the Medication and Administration Treatment Record, for the following: Resident's name, medication name, medication dose, medication route and frequency of medication administration. NJAC: 8-39-27.1 (a)

COMPLAINT #: NJ 9, NJ 1 Based on interviews, record review, and review of pertinent facility documents on 7/21/2020, 7/23/2020 and 7/24/2020, it was determined that the facility failed to report incidents for 3 of 5 sampled residents Resident #1, Resident #2 and Resident #5, to the New Jersey Department of Health (NJDOH), as required and according to the facility's policy. This deficient practice is evidenced by the following: On 7/21/2020 at 10:40 a.m., the surveyor reviewed the Medical Record (MR) for Resident #1. According to the face sheet (FS), Resident #1 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool, dated 5/19/20, Resident #1's cognitive function was intact and required assistance with Activities of Daily Living (ADL). Review of a Nursing Clinical Note (NCN) dated 10/3/19 at 10:29 a.m.,CNA passing by room found Resident #2, yelling, cursing .towards roommate Resident #1 .Upon entering the room .Resident #1 begin to state that the Resident #2 has done this before. Resident #1 attempted to be removed from area when Resident #2 used w/c to strike Resident #1's w/c in retaliation. Resident #1 removed from room Primary Medical Doctor notified with new order to send out for emergency crisis via psych [psychology] in ER [emergency room ] .911 and police notified .Resident #2 left facility via stretcher transportation and police escort. The facility could not provide evidence that NJDOH was notified of the incident involving Resident #1 and Resident #2 and police were called to facility. On 7/21/2020 at 10:50 a.m., the surveyor reviewed the MR for Resident #2. According to the FS, Resident #2 was admitted to the facility originally on 12/3/19 and again on 6/18/19, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, an assessment tool, dated 5/19/20, Resident #2's cognitive function was intact and was independent with ADL. Review of NCN dated 10/15/19 4:43 p.m., At around 4 pm, resident was asked to hand his/her cigarettes over to us. He/she refused so Director of Nursing (DON), Assistant Director of Nursing (ADON) and [writer] told him that we will search his/her room which he/she refused. He/she stated I want the police here as my witness. Administrator made aware and called the police .police came and was escorted to the resident's room .Administrator, DON, ADON and [writer] searched his/her room .There was a lighter and a matchbox found The facility could not provide evidence that NJDOH was notified of smoking paraphernalia being found in Resident #2's room and police were called to facility. A review of a police report dated 11/1/19 at 1:35 p.m., supplied by the facility indicated the following: Officer met with [Resident #5] and Administrator regarding an issue involving [Resident #2]. Resident #5 stated that he/she feels harassed by Resident #2 who has been taking pictures of him/her and other patients in the facility .Resident #5 is concerned with what Resident #2 is doing with these photographs,,,Resident #5 also stated that Resident #2 purposely does things to annoy the other patients. The facility could not provide evidence that NJDOH was notified Resident #5 felt harassed by Resident #2 taking pictures of him/her and other residents in facility and police were called to file a report. A review of NCN dated 2/25/2020 at 12:58 p.m., indicated [Resident #2] noted leaving facility .refusing to sign himself/herself on leave per facility rules. Administrator and Housekeeping director attempted redirect. Police notified .Resident #2 continued to wheel himself/herself away from the facility despite encouragement from employees and police to return to the building. The facility could not provide evidence that NJDOH was notified of police being called to the facility for Resident #2 refusing to sign out on leave of facility. Review of Social Services Clinical Notes (SSCN) from 10/11/19 through 3/6/2020 included that on 10/11/19 at 1:59 p.m., SW met with Resident #2. He/she was reminded that he/she is refusing to comply with smoking policy . On 2/14/2020 at 10:04 a.m. Resident was noted to be smoking in front of building, which is not in area designated for smoking .SW attempted to remind resident of smoking policy and rules. Resident was told he/she cannot keep lighters/matches on himself/herself. On 3/6/2020 at 4:38 p.m. SW noticed resident was in front of building smoking .When he/she came back in, SW asked him/her if he/she had a lighter or matches with him/her resident denied, however SW saw resident had lit cigarette by [him/herself] SW and Administrator asked him/her to hand over matches/lighter .he/she denied having .Resident yelled at SW and Administrator .he/she wanted police, so police were called. They asked him/her to open up his/her pouch around his/her neck and matches were found. They restated to resident .cannot keep lighters/matches with him/her .that he/she needs to let nursing staff hold them. The facility could not provide evidence that NJDOH was notified of police being called to facility for Resident #2 not complying with smoking policy of facility. A review of NCN dated 3/18/2020 at 12:16 p.m., Resident #2 noted yelling at staff when redirected to room, Resident stated when he/she leaves he/she will return with a 44 magnum .stated doesn't get angry . he/she settles the score .Staff continue to redirect .Administrator made aware. Police notified and were in facility speaking to Resident #2. The facility could not provide evidence that NJDOH was notified of police being called to facility for Resident #2's behavior. During an interview on 7/24/2020 at 11:43 a.m., the Director of Social Services (DSS) stated that the incidents involving Resident #2 with Resident #1 and incident with Resident #5 should have been reported to the NJDOH and was not done. During an interview on 7/24/2020 at 12:32 p.m., the Administrator stated the incident with Resident #2 and Resident #1 was not reported to the NJDOH but should have been. When the Administrator was asked if the incident with Resident #2 and Resident #5 was reported to the NJDOH, she did not feel we should have notified the NJDOH because the police were called. The Administrator also stated the incidents involving police assistance being called for Resident #2 were not reported to the NJDOH. Review of the facility's policy titled, Incident and Accident Policy with an Implemented date 9/99, a Revised date 9/17 and a Reviewed date of 1/20, included but was not limited to the following: Policy: Accidents or incidents occurring in the facility or on the facility property are to be reported. An incident is any occurrence not consistent with the routine operation of the facility, normal care of the resident, .or observation of a condition which might become a safety hazard. Purpose To provide a safe environment for residents, visitors and employees. 10. Notification of the following as determined: a)Ombudsman b) Department of Health c) Family/resident representative d) Physician/Medical director e)Police or appropriate authority. NJAC 8:39-9.4(f)

COMPLAINT #: NJ 9, NJ 1 Based on interviews and record review, as well as review of pertinent facility documents on 7/21/2020, 7/23/2020 and 7/24/2020, it was determined that the facility failed to investigate incidents for 3 of 5 sampled residents Resident #1, Resident #2 and Resident #5, as required and according to the facility's policy. This deficient practice is evidenced by the following: On 7/21/2020 at 10:40 a.m., the surveyor reviewed the Medical Record (MR) for Resident #1. According to the Face Sheet (FS), Resident #1 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool, dated 5/19/20, Resident #1's cognitive function was intact and required assistance with Activities of Daily Living (ADL). Review of a Nursing Clinical Note (NCN) dated 10/3/19 at 10:29 a.m.,CNA passing by room found Resident #2, yelling, cursing .towards roommate Resident #1 .Upon entering the room .Resident #1 begin to state that the Resident #2 has been this way with him on several occasions. Resident #1 attempted to be removed from area when Resident #2 used w/c to strike Resident #1's w/c in retaliation. Resident #1 removed from room Primary Medical Doctor notified with new order to send out for emergency crisis via psych [psychology] in ER [emergency room ] .911 and police notified .Resident #2 left facility via stretcher transportation and police escort. The facility could not provide documentation or evidence that the incident involving Resident #1 and Resident #2 was thoroughly investigated. On 7/21/2020 at 10:50 a.m., the surveyor reviewed the MR for Resident #2. According to the FS, Resident #2 was admitted to the facility originally on 12/3/19 and again on 6/18/19, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, an assessment tool, dated 5/19/20, Resident #2's cognitive function was intact and was independent with ADL. Review of a NCN dated 10/3/19 at 10:29 a.m.,CNA passing by room found Resident #2, yelling, cursing .towards roommate Resident #1 .Upon entering the room .Resident #1 begin to state that the Resident #2 has been this way with him on several occasions. Resident #1 attempted to be removed from area when Resident #2 used w/c to strike Resident #1's w/c in retaliation. Resident #1 removed from room Primary Medical Doctor notified with new order to send out for emergency crisis via psych [psychology] in ER .911 and police notified .Resident #2 left facility via stretcher transportation and police escort. The facility could not provide documentation or evidence that this incident involving Resident #1 and Resident #2 was thoroughly investigated. Review of NCN dated 10/15/19 4:43 p.m., At around 4 pm, resident was asked to hand his/her cigarettes over to us. He/she refused so Director of Nursing (DON), Assistant Director of Nursing (ADON) and [writer] told him that we will search his/her room which he/she refused. He/she stated I want the police here as my witness. Administrator made aware and called the police .police came and was escorted to the resident's room .Administrator, DON, ADON and [writer] searched his/her room .There was a lighter and a matchbox found The facility could not provide documentation or evidence that smoking paraphernalia being found in Resident #2's room was thoroughly investigated. A review of NCN dated 2/25/2020 at 12:58 p.m., indicated [Resident #2] noted leaving facility .refusing to sign himself/herself on leave per facility rules. Administrator and Housekeeping director attempted redirect. Police notified .Resident continued to wheel himself/herself away from the facility despite encouragement from employees and police to return to the building. The facility could not provide documentation or evidence that this incident of Resident #2 refusing to sign out on leave of facility was thoroughly investigated. Review of Social Services Clinical Notes (SSCN) from 10/11/19 through 3/6/2020 included that on 10/11/19 at 1:59 p.m., SW met with Resident #2. He/she was reminded that he/she is refusing to comply with smoking policy . On 2/14/2020 at 10:04 a.m. Resident was noted to be smoking in front of building, which is not in area designated for smoking .SW attempted to remind resident of smoking policy and rules. Resident was told he/she cannot keep lighters/matches on himself/herself. On 3/6/2020 at 4:38 p.m. SW noticed resident was in front of building smoking .When he/she came back in, SW asked him/her if he/she had a lighter or matches with him/her resident denied, however SW saw resident had lit cigarette by himself SW and Administrator asked him/her to hand over matches/lighter .he/she denied having .Resident yelled at SW and Administrator .he/she wanted police, so police were called. They asked him/her to open up his/her pouch around his/her neck and matches were found. They restated to resident .cannot keep lighters/matches with him/her .that he/she needs to let nursing staff hold them. The facility could not provide documentation or evidence that this incident with Resident #2 not complying with smoking policy of facility was thoroughly investigated. A review of NCN dated 3/18/2020 at 12:16 p.m., Resident #2 noted yelling at staff when redirected to room, Resident stated when he/she leaves he/she will return with a 44 magnum .stated doesn't get angry . he/she settles the score .Staff continue to redirect .Administrator made aware. Police notified and were in facility speaking to Resident #2. The facility could not provide documentation or evidence that this incident with Resident #2's behavior was thoroughly investigated. On 7/21/2020 at 10:30 a.m., the surveyor reviewed the MR for Resident #5. According to the FS, Resident #5 was admitted to the facility originally on 9/17/16 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, an assessment tool, dated 6/2//20, Resident #5's cognitive function was intact and required assistance from staff with ADL A review of a police report dated 11/1/19 at 1:35 p.m., supplied by the facility indicated the following: Officer met with [Resident #5] and Administrator regarding an issue involving [Resident #2]. Resident #5 stated that he/she feels harassed by Resident #2 who has been taking pictures of him/her and other patients in the facility .Resident #5 is concerned with what Resident #2 is doing with these photographs,,,Resident #5 also stated that Resident #2 purposely does things to annoy the other patients. The facility could not provide documentation or evidence that this incident with Resident #5 felt harassed by Resident #2 taking pictures of him/her and other residents in the facility was thoroughly investigated. During an interview on 7/24/2020 at 11:43 a.m., the Director of Social Services (DSS) stated that the incidents involving Resident #2 with Resident #1 and incident with Resident #5 should have been investigated and was not done. When asked if incidents with Resident #2 not following the smoking contract were investigated, the DSS was not sure if it should have been done. During an interview on 7/24/2020 at 12:32 p.m., the Administrator stated the facility did not do an incident investigation involving Resident #2 and Resident #1, because staff stepped in to handle the problem and the police were called. When asked if an incident investigation was done involving Resident #2 and Resident #5, the Administrator stated the police were called to the facility and met with Resident #5 and the Administrator. A police report was made and the Administrator stated she thought that would have sufficed. When asked if incidents with Resident #2 not following the smoking contract were investigated the Administrator was unable to provide any documentation. Review of the facility's policy titled, Incident and Accident Policy with an Implemented date 9/99, a Revised date 9/17 and a Reviewed date of 1/20, included but was not limited to the following: Policy: Accidents or incidents occurring in the facility or on the facility property are to be reported. An incident is any occurrence not consistent with the routine operation of the facility, normal care of the resident, .or observation of a condition which might become a safety hazard. Purpose To provide a safe environment for residents, visitors and employees. 9. Documentation and investigative action: a) The charge nurse and/or the department director or supervisor will document the incident and conduct an immediate investigation of the accident or incident. b)The Incident/Accident Form will be used for residents, employees and visitors. d) Every attempt will be made to ascertain the cause of the accident/incident. e) The Administrator and Director of Nursing or designees will be made aware of all such incidents occurring in the facility and will review completed reports g)The Administrator/designee is responsible for coordinating the investigation and assuring that appropriate action is taken. NJAC 8:39-4.1(a)5

COMPLAINT #: NJ 9, NJ 1 Based on interviews and record review, as well as review of pertinent facility documents on 1/21/2020, 1/23/2020 and 1/24/2020 it was determined that the facility failed to revise and update the comprehensive care plan (CP) for 3 of 5 sampled residents Resident #1, Resident #2 and Resident #5, as required and according to the facility's policy. This deficient practice is evidenced by the following: On 7/21/2020 at 10:40 am, the surveyor reviewed the Medical Record (MR) for Resident #1. According to the Face Sheet (FS), Resident #1 was admitted to the facility originally on 8/9/19, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool, dated 5/19/2020, Resident #1's cognitive function was intact and required assistance with Activities of Daily Living (ADL). Review of a Nursing Clinical Note (NCN) dated 10/3/19 at 10:29 a.m.,CNA passing by room found Resident #2, yelling, cursing .towards roommate Resident #1 .Upon entering the room .Resident #1 begin to state that the Resident #2 has been this way with him on several occasions. Resident #1 attempted to be removed from area when Resident #2 used w/c to strike Resident #1's w/c in retaliation. Resident #1 removed from room Primary Medical Doctor notified with new order to send out for emergency crisis via psych [psychology] in ER [emergency room ] .911 and police notified .Resident #2 left facility via stretcher transportation and police escort. Review of Resident #1's CP indicated no updated or revised interventions developed to evaluate the effectiveness. On 7/21/2020 at 10:50 am, the surveyor reviewed the MR for Resident #2. According to the FS, Resident #2 was admitted to the facility originally on 12/3/19 and again on 6/18/19, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, an assessment tool, dated 5/19/20, Resident #2's cognitive function was intact and was independent with ADL. Review of the CP under Problems Resident #2 is a smoker 2/17/2020-5/16/2020. Goals Resident #2 will demonstrate safe smoking practices and adhere to the facility smoking policy. 12/3/19 - 5/16/2020 Interventions 12/3/19 - 5/16/19 Smoking assessment at admission and as needed. Educate Resident #2 on facility smoking policy. Smoking supplies will be maintained by staff. Access to supplies will be provided at smoking times only. Smoking times are between 8am - 8pm. Smoking will be done in designated outside areas without supervision. Evaluate periodically if smoking supervision is needed. Review of the CP under Problems Resident #2 has episodes of becoming irritable, angry, physically (banging wheelchair into room partner) and verbally aggressive .difficult to redirect, disruptive. resident has episodes of yelling/screaming at others .Resident is non-compliant with rules and regulations of facility .It has been noted that resident posts on social media, inappropriate pictures, writing co-residents names without permission . 7/15/19 - 11/12/19 Under Goals Resident will decrease verbally, physically aggressive and inappropriate behavior as evidenced by no verbally/physically/inappropriate behavior and by complying with care, facility policies and redirection daily. 7/15/19-11/12/19 Under Interventions Provide redirection and reminders as needed, educate regarding appropriate and inappropriate behavior 7/15/19-11/12/19 Monitor resident's behavior, redirect .remove from situation as needed 7/15/19-11/12/19 Consult with Ombudsman's office and Dept. of Health as needed 7/15/19-11/12/19 The Smoking Safety Data Collection and Assessment form completed on 6/19/19 and 12/20/19 showed that Resident #2 was: orientated to person, time and place, resident has the ability to verbalize understanding of smoking standard procedure, resident demonstrate ability to make own decision in relation to daily activities, resident able to verbalize the location of the smoking area, resident is compliant with keeping smoking materials at nurses' station. Review of a Nursing Clinical Note (NCN) dated 10/3/19 at 10:29 a.m.,CNA passing by room found Resident #2, yelling, cursing .towards roommate Resident #1 .Upon entering the room .Resident #1 begin to state that the Resident #2 has been this way on several occasions. Resident #1 attempted to be removed from area when Resident #2 used w/c to strike Resident #1's w/c in retaliation. Resident #1 removed from room Primary Medical Doctor notified with new order to send out for emergency crisis via psych [psychology] in ER [emergency room ] .911 and police notified .Resident #2 left facility via stretcher transportation and police escort. Review of NCN dated 10/15/19 4:43 p.m., At around 4 pm, resident was asked to hand his/her cigarettes over to us. He/she refused so Director of Nursing (DON), Assistant Director of Nursing (ADON) and [writer] told him that we will search his/her room which he/she refused. He/she stated I want the police here as my witness. Administrator made aware and called the police .police came and was escorted to the resident's room .Administrator, DON, ADON and [writer] searched his/her room .There was a lighter and a matchbox found A review of a police report dated 11/1/19 at 1:35 p.m., supplied by the facility indicated the following: Officer met with [Resident #5] and Administrator regarding an issue involving [Resident #2]. Resident #5 stated that he/she feels harassed by Resident #2 who has been taking pictures of him/her and other patients in the facility .Resident #5 is concerned with what Resident #2 is doing with these photographs,,,Resident #5 also stated that Resident #2 purposely does things to annoy the other patients. A review of NCN dated 2/25/2020 at 12:58 p.m., indicated Resident #2 noted leaving facility .refusing to sign himself/herself on leave per facility rules. Administrator and Housekeeping director attempted redirect. Police notified .Resident continued to wheel himself/herself away from the facility despite encouragement from employees and police to return to the building. A review of NCN dated 3/18/2020 at 12:16 p.m., Resident #2 noted yelling at staff when redirected to room, Resident stated when he/she leaves he/she will return with a 44 magnum .stated doesn't get angry . he/she settles the score .Staff continue to redirect .Administrator made aware. Police notified and were in facility speaking to Resident #2. Review of Social Services Clinical Notes (SSCN) from 10/11/19 through 3/6/2020 included that on 10/11/19 at 1:59 p.m., SW met with Resident #2. He/she was reminded that he/she is refusing to comply with smoking policy . On 2/14/2020 at 10:04 a.m. Resident was noted to be smoking in front of building, which is not in area designated for smoking .SW attempted to remind resident of smoking policy and rules. Resident was told he/she cannot keep lighters/matches on himself/herself. On 3/6/2020 at 4:38 p.m. SW noticed resident was in front of building smoking .When he/she came back in, SW asked him/her if he/she had a lighter or matches with him/her resident denied, however SW saw resident had lit cigarette by him/herself SW and Administrator asked him/her to hand over matches/lighter .he/she denied having .Resident yelled at SW and Administrator .he/she wanted police, so police were called. They asked him/her to open up his/her pouch around his/her neck and matches were found. They restated to resident .cannot keep lighters/matches with him/her .that he/she needs to let nursing staff hold them. There were no revisions or updated interventions and goals to evaluate the effectiveness of imcidents that were identified involing Resident #2. Review of Resident #2's Person-Centered Care Plan Summary(s) for: 6/26/19, 10/1/19, 12/31/19, 2/18/20 and 5/26/20 did not identify new care plan interventions. Review of IDCP team Signatures did not indicate presence of Medical Director. On 7/21/2020 at 10:30 a.m., the surveyor reviewed the MR for Resident #5. According to the FS, Resident #5 was admitted to the facility originally on 9/17/16 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, an assessment tool, dated 6/2//20, Resident #5's cognitive function was intact and required assistance from staff with ADL. A review of a police report dated 11/1/19 at 1:35 p.m., supplied by the facility indicated the following: Officer met with [Resident #5] and Administrator regarding an issue involving [Resident #2]. Resident #5 stated that he/she feels harassed by Resident #2 who has been taking pictures of him/her and other patients in the facility .Resident #5 is concerned with what Resident #2 is doing with these photographs,,,Resident #5 also stated that Resident #2 purposely does things to annoy the other patients. Review of Resident #5's CP found no updated interventions related to this incident for Resident #5. During an interview on 7/24/2020 at 11:43 a.m., the Director of Social Services (DSS) stated new issues should have been care planned and were not done. When asked by surveyor how would staff know what care to provide if interventions were not documented in the CP the DSS stated she did not know. The Surveyor reviewed the facilities Care Plan Policy Implemented: 12/99, Revised 1/20. Policy It is the policy of the facility to ensure that all residents will have appropriate care plan developed by the interdisciplinary team to ensure quality care and to promote the resident's plan of care. Purpose To ensure that each resident benefits from the combined expertise of all involved members of the team through an integrated treatment plan. Procedure: 2. Based on the assessment the care plan should contain the following information: a) Objective and functional problem b) Measurable long term goal with a time frame to achieve the goals c) Interdisciplinary interventions 3. The team will continue to gather data and develop care plans appropriate to the resident's needs. 4. Care plans are reviewed and updated during the interdisciplinary care plan meeting and as needed. 6. Care plans will be reviewed and updated as needed by each discipline and new issues will be addressed as appropriate. NJAC 8:39-11.2(e) 2

COMPLAINT #: NJ 9, NJ 1 Based on record review and review of other documentation, it was determined that the facility failed to follow-up and document the circumstance of the facility initiated discharge for a resident who ready for discharge from the hospital for 1 of 3 medical records reviewed. (Resident #2). This deficient practice was evidenced by the following: On 7/17/2020, Resident #2 was ready for discharge from the hospital back to the facility. The Department of Health received a phone call from a social worker at the hospital where Resident #2 was admitted . The social worker stated that the facility is refusing to take back the resident. The resident was sent to the hospital for medical issues involving lower extremities on 7/9/2020. There was no documented evidence in the medical record that the physician provided information about the facility's inability to meet the needs of the resident on or close to the actual discharge date of [DATE]. Review of the facility's policy titled, Discharge Planning Policy with an Implemented date 11/99, a Revised date 10/19 included but was not limited to the following: Policy: The organization will provide sufficient notice to residents to ensure a safe and orderly transfer or discharge from the facility. 2. Residents may be considered for a discharge when one of the following criteria are met: - The safety of individuals in the facility is endangered - The resident's needs can no longer be met by the facility 5. Social Services will provide written notification to the resident/responsible party prior to being discharged or transferred: This notification will include: - Reason for an effective date of transfer - The timing of the notification will be based on state and federal regulations. 14. The resident's attending physician must approve the discharge order prior to any discharge from the organization.

C#: NJ 685, NJ 147, NJ 886 Based on interviews and record review, as well as review of pertinent facility documents on 1/23/2020, 1/24/2020, 1/27/2020, 1/28/2020, 1/29/2020 and 1/30/2020, it was determined that the facility failed to provide Activities of Daily Living (ADLs) for 3 of 13 Residents (Resident #5, #10, and #12) reviewed for ADLs. This deficient practice is evidenced by the following: 1. According to the FACE SHEET (FS), Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set MDS, an assessment tool, dated 3/22/19, Resident #5's cognitive function was moderately impaired and required extensive assistance from staff with ADLs. The Care Plan (CP) initiated on 3/28/18 showed that the Resident was at risk for falls related to decreased mobility. The Interventions included but were not limited to: give Resident verbal reminders to not ambulate or transfer without assistance and assist with toileting. The CNA (Certified Nurse Aide) - DAILY ADL SCORING OF RESIDENT (DADL) dated 7/2019 under the section Category showed the following: bed mobility, eating, transfer, toileting, locomotion in unit, and walking in corridor. The same form showed no documentation to indicate that Resident #5 was assisted with ADLs on 7/6/19, 7/10/19, 7/12/19, 7/13/19, 7/14/19, 7/15/19, 7/16/19, 7/19/19, 7/20/19, 7/21/19, 7/26/19, 7/29/19, 7/30/19 and 7/31/19 during day (7:00 am to 3:00 pm shift), and on 7/2/19, 7/6/19, 7/7/19, 7/16/19, 7/21/19, and 7/25/19 during the evening (3:00 pm to 11:00 pm shift) The Progress Notes (PNs) for Resident #5 for 7/2019 showed no documentation to indicated that the Resident was assisted with ADLs on the aforementioned dates and times. 2. According to the FS, Resident #10 was initially admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the MDS dated ,[DATE], Resident #10 had severe cognitive impairment and required extensive assistance from staff with ADLs. The CP initiated on 10/5/18 showed that the Resident had decline in independence with toilet transfers. The intervention included but was not limited to: required extensive assistance with toilet transfers. The CP initiated on 10/5/18 showed that the Resident had decreased independence in self-care tasks. The interventions included but were not limited to: encourage complete lower body care with extensive assistance and encourage complete upper body care with moderate assistance. The CP initiated on 12/3/18 showed that the Resident had decreased ability to transfer independently. The intervention included but was not limited to: provide appropriate level of assist to promote safety of the Resident. The CNA-DADL for 4/2019 under the Category showed the following: bed mobility, eating, transfer, toileting, locomotion in unit, and walking in corridor. The same form showed no documentation to indicate that the Resident was assisted with ADLs on 4/2/19, 4/6/19, 4/26/19, 4/27/19, 4/28/19 and 4/30/19 during night shift, on 4/4/19, 4/5/19, 4/13/19, 4/19/19 and 4/28/19 during day shift and on 4/3/19, 4/11/19, 4/13/19, 4/18/19, 4/28/19 and 4/30/19 during evening shift. The PNs for Resident #10 for 4/2019 showed no documentation to indicate that the Resident was assisted with ADLs on the aforementioned dates and times. 3. According to the FS, Resident #12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #12 had intact cognitive function and required extensive assistance from staff with ADLs. The CP initiated on 5/15/19 showed that the Resident had a potential for skin integrity impairment related to decreased mobility and incontinence. The intervention included but was not limited to: assist with toileting. The CNA-DADL for 1/2020 under Category showed the following but was not limited to: toileting. The same form showed no documentation to indicate that the Resident was assisted with toileting on 1/1/20, 1/3/20, 1/6/20, 1/9/20 and 1/16/20 during the night shift, on 1/6/20, 1/7/20, 1/13/20, 1/17/20, 1/20/20, 1/26/20, and 1/29/20 during day shift and on 1/18/20 to 1/29/20 during the evening shift. The PNs for Resident #12 for 1/2020 showed no documentation to indicate that the Resident was assisted with toileting on the aforementioned dates and times. The surveyor conducted an interview with LPN #1 on 1/29/20 at 10:07 am. The LPN revealed that CNAs were responsible for documenting on ADL sheets. She further revealed that nurse supervisors would remind CNAs to document every shift in the CNA-DADL book for all Residents. She stated that if there were blanks in the book, that meant that care was not provided. The surveyor conducted an interview with CNA #1 (a full time CNA during day shift) on 1/29/20 at 10:39 am. The CNA stated that it was her responsibility to document on ADLs for all Residents she took care of on every shift she worked for. She revealed it was important to document on the CNA-DADL sheets to make sure the ADLs were done. If there was no documentation, nobody knew if it was done. She further revealed that she could not recall if ADLs were provided to aforementioned residents without her documentation to back her up. The surveyor conducted an interview with Director of Nursing (DON) on 1/30/20 at 11:02 am. The DON revealed that CNAs were reminded to document on the CNA-DADL and Unit Managers (UM) were responsible for checking if the ADL books were signed by CNAs. The facility's job description for POSITION TITLE: CERTIFIED NURSE AIDE (CNA) dated 8/2005, showed that: .RESPONSIBILITIES/ACCOUNTABILITIES .3 Provides maximum resident care services within limits defined by delegated tasks; 4 Assumes responsibility for varied resident care duties as assigned by charge nurse .5 Bathes the resident in bed, tub or shower, combs hair, cleans and cuts fingernails and gives shampoos .11 Participates in the formulation and follow through of the resident's nursing care plan; .13 Assists all residents with their meals and provides in between meal nourishment, as well as providing fresh ice and water to the resident's bedside; 14 Answers resident's call light or bell, delivers messages, administers bedpans and urinals, cleans areas of spillage or accidents caused by the resident .20 Receives and escorts visitors, collects, charts, records and reports . NJAC 8:39-4.1(12) NJAC 8:39-27.2(h)

C#: NJ 123 Based on interviews, review of the medical records, and pertinent facility documents on 1/23/2020, 1/24/2020, 1/27/2020, 1/28/2020, 1/29/2020 and 1/30/2020, it was determined that the facility's Nursing staff failed to accurately document and reconcile the administration of controlled medication for 1 of 3 Residents (Resident #8) reviewed for controlled substance administration. This deficient practice is evidence by the following: 1. According to the Admission Record Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool dated 8/24/19, revealed that Resident #8's cognitive function was severely impaired. The Care Plan (CP) initiated on 4/21/14 showed that Resident #8 had pain related to Melanoma to the Right Toe. Interventions included but were not limited to: pain assessment and administer pain medication as ordered. The physician's orders [REDACTED]. The Medication Administration Record (MAR) form for 8/2019 showed the aforementioned orders and was signed for administration of the medication as ordered. The Controlled Medication Utilization Record (CMUR) for 8/2019 showed that the [MEDICATION NAME] dose recorded as administered on the MAR was not recorded on CMUR to indicate that the [MEDICATION NAME] was taken out of the bottle and administered to Resident #8 on 8/22/19 at 12:00 pm, on 8/24/19 at 10:00 pm and on 8/26/19 at 4:00 am and 4:00 pm, which was not according to the facility's policy. The PO showed that the Resident had an order dated 8/22/19 at 1:30 pm to continue [MEDICATION NAME] standing order (ordered on [DATE]) and start [MEDICATION NAME] 0.25 ml/5 mg sublingual every one (1) hour as needed (PRN) for breakthrough pain. The CMUR showed the aforementioned order. The same form showed that 0.25 ml dose of [MEDICATION NAME] was signed out on 8/23/19 at 1:00 am, 3:00 am, 5:00 am, 9:00 pm and 11:00 pm, on 8/25/19 at 9:00 pm and 11:00 pm, on 8/26/19 at 11:00 pm, and on 8/28/19 at 1:00 am, at 3:00 am and at 5:00 am. The MAR showed under the PRN (as needed) Medication (PRNM) for 8/2019 showed the aforementioned order. It further showed that the aforementioned medication was not documented to indicate that the [MEDICATION NAME] was administered to Resident #8 on the specified dates and times. The surveyor conducted an interview with Licensed Practical Nurse (LPN #1, the assigned nurse to Resident #8 on 8/22/19, 8/24/19 and 8/25/19 ) on 1/28/2020 at 1:45 pm. The LPN revealed that whenever a controlled substance, such as [MEDICATION NAME], was taken out of a bottle, it had to be signed for on the CMUR. She further revealed that she did not know why she did not document that medicine [MEDICATION NAME] was taken out of a bottle to be administered to Resident #8 on the aforementioned dates and times. She stated that she did not know why the medicine count was not affected and if she administered the medication [MEDICATION NAME] on the aforementioned dates and times. She further stated that she did not know why she signed the medicine out of the CMUR on 8/25/19 at 9:00 pm and 11:00 pm, however, did not document as administered on the MAR. She stated that she must have forgotten to document. The surveyor attempted to interview the Registered Nurses (RN), assigned to Resident #8 on the aforementioned dates and times, on 1/29/2020 and 1/30/2020. However, they were not available. The facility's undated job description for STAFF NURSE showed that: .RESPONSIBILITIES/ACCOUNTABILITIES .13 Maintains accurate resident care records and documents pertinent data reflecting the use of the nursing process; .18 Dispenses medication and performs treatments, as requested, and in accordance with Care Center policies and procedures . The facility's policy titled PAIN MANAGEMENT POLICY, revised on 9/2019 showed that: POLICY Residents will be assessed for pain with interventions attempted to manage their pain. Residents will be screened routinely for the presence of pain and pending the results, interventions to alleviate pain be initiated as appropriate .PR[NAME]EDURE .3. On a daily basis residents will be screened for the presence of pain .The documentation will be in the Medication Administration Record (MAR) .7. The administration of the PRN (as needed) medication will be documented on the MAR . The facility's policy titled CONTROLLED DRUG POLICY, revised on 2/2019 showed that: .PR[NAME]EDURE .3. When administering controlled medications, the controlled drug inventory is signed when medication is removed . The facility's policy titled MEDICATION AND TREATMENT RECORD ADMINISTRATION revised on 3/2016 and reviewed on 9/2019 showed that: POLICY: Medications are administered by licensed staff members according to policies and procedures. PURPOSE To ensure competent and safe medication administration to residents .PR[NAME]EDURE 6 .q. Document medication administration by charting it in residents clinical record . NJAC 8:39-29.2 (d) NJAC 8:39-29.7 (c)

Based on observation, interview, and record review, it was determined that the facility failed to maintain infection control practices during a wound treatment observation for 1 of 2 residents (Resident #62) reviewed. This deficient practice was evidenced by the following: On 04/18/19 at 11:28 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment for [REDACTED]. The surveyor observed the LPN prepare a clean field on the resident's over bed table. The Certified Nursing Assistant (CNA), assigned to the resident, assisted the LPN with the positioning of resident #62. The surveyor observed the CNA wash her hands for 10 seconds and then she left the room. The surveyor observed the LPN prepare the wound care supplies on top of the clean field, then washed her hands for eight seconds. The surveyor observed the CNA return to the resident's room and wash her hands for 10 seconds. The surveyor observed the LPN remove the soiled dressing from the wound area, remove her gloves and wash her hands for 10 seconds. The LPN donned clean gloves, cleansed the wound, applied a medicated dressing and covered the wound. She then washed her hands for five seconds. The surveyor observed the CNA put on two pairs of gloves. The CNA provided incontinent care for Resident #62 and then removed one pair of gloves. The surveyor asked the CNA if it was her practice to wear two pairs of gloves at one time. The CNA stated that she always uses two pairs of gloves so that she doesn't have to go through the whole hand washing process. The CNA provided incontinent care a second time and stated, see, that's why I wear two sets of gloves. She then removed the second pair of gloves and washed her hands for five seconds. On 04/18/19 at 2:20 PM, the surveyor discussed the above concerns with the Administrator and the Director of Nursing (DON). The Administrator and the DON both stated that the staff should definitely not be double gloving. A review of the facility's policy for Hand Hygiene dated 1/2001, revised 1/1/2011 and 01/07/19, indicated under the Policy statement Procedure #5: The organization follows CDC Hand Hygiene Guidelines and Wet hands and apply skin cleanser, then wash hands vigorously for 20-30 seconds. NJAC 8:39-19.4 (a) (1)

Based on observation, interview and record review, it was determined that the facility failed to a.) implement a barrier cream and peri-guard ointment to Resident #21 who was incontinent and at risk for skin impairment and b.) perform a body assessment by a Registered Nurse (RN) according to the standard of practice. There was no evidence that Resident #21 received the implemented intervention of a barrier cream and peri-guard from February/March 2017 until January 18, 2018 for a total of 11 months. The resident developed an unstageable pressure wound to the sacral area on 1/18/18 which required chemical debridement. This deficient practice was identified for 1 of 3 residents reviewed for facility-acquired pressure ulcers (Resident #21) and was evidenced by the following: On 2/13/18 at 10:15 a.m., the surveyor observed Resident #21 seated in a wheelchair in the activity room. The resident was participating in a coloring and drawing activity with the assistance of recreation staff. On that same day and time, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the resident was cognitively impaired and had periods of agitation manifested by screaming and hitting others. The RN/UM also stated that Resident #21 had a facility acquired wound to the sacral area and a right [CONDITION(S)] secondary to a fall at home and fell a few months ago at the facility. On that same day at 10:31 a.m., the surveyor reviewed the medical record. The record indicated Resident #21 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed that Resident #21 had a care plan dated 2/16/17 for potential for skin integrity impairment secondary to decreased mobility. Interventions included to apply barrier cream, provide pressure reduction foam mattress for bed, shear friction precautions and assist with toileting. The care plan was revised on 3/7/17 to add potential for skin integrity impairment secondary to decreased mobility and use of anticoagulants and incontinence with interventions which included to apply skin barrier cream and apply peri-guard. The revised care plan interventions were continued on a quarterly basis on the following dates: 5/30/17, 8/29/17 and 11/29/17. Review of the January and February 2018 physician orders (PO) and Treatment Administration Record (TAR) revealed a PO dated 4/28/17 for weekly skin assessment every Monday on the 7-3 shift. Further review of the medical record did not reveal physician orders for preventative barrier cream and/or peri-guard and there was no documented evidence in the medical record that the resident received preventative barrier cream and/or peri-guard. A review of the February 2017 through February 2018 Nursing Care Log for the CNA did not show a barrier cream or peri-guard application to the sacral area of Resident #21. On 2/14/18 at 10:32 a.m., the surveyor interviewed the RN/UM. The RN/UM informed the surveyor that it was not the Certified Nursing Assistant's (CNA's) responsibility to document any skin impairment of the resident. The CNA was only expected to report it directly to the nurse and it was nurse's responsibility to assess and document the observed skin impairment and notify the physician. On that same day at 11:05 a.m., the surveyor reviewed the Weekly Wound Documentation (WWD). The WWD dated 1/18/18 revealed an onset date for an unstageable sacral wound. According to the 1/18/18 WWD, the sacral wound measurement was documented as 1.5 centimeters (cm) x 1.0 cm with a small amount of drainage. The wound bed was described as 50% epithelial and 50% slough and the wound treatment was initiated with Santyl (an ointment used to remove [debride] dead tissue from wounds). According to the National Pressure Ulcer Advisory Panel (NPUAP), an organization recognized by the Center for Medicare and Medicaid Services (CMS): The Unstageable bed sore is defined as full thickness tissue loss in which the base of the ulcer is covered by slough, a yellow, tan, gray, green or brown and/or eschar/black in the wound bed, and This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface that developed over time. On the same day and time the surveyor reviewed the January 2018 Treatment Administration Record (TAR). The TAR showed that there was an order dated 1/18/18 to clean sacral wound with normal saline solution (NSS), pat to dry, apply santyl cover with dermalevin in a.m. for 14 days, then re-evaluate. A review of the February 2018 Physician Order (PO) and TAR revealed the same. The surveyor reviewed Section M (an assessment tool for Skin and Ulcer Treatments) of the 2/22/17 Initial Minimum Data Set (MDS, a comprehensive assessment tool), and the 5/25/17, 8/25/17 and 11/25/17 Quarterly MDS indicated that Resident #21 was at risk for development of pressure ulcer and that the resident received ointments/medication to prevent the development of pressure ulcer. Further review of the Physician Orders (PO) and Treatment Administration Record (TAR) from February 2017 through January 18, 2018 did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/15/18 at 10:11 a.m., the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN informed the surveyor that he was the assigned nurse who documented and observed the sacral wound. The LPN stated that Resident #21 was cognitively impaired and incontinent of both bowel and bladder elimination. The LPN stated that he signed the 1/15/18 weekly wound assessment and the skin was intact. The LPN informed the surveyor that on 1/18/18, three days after the 1/15/18 weekly wound assessment; the CNA notified and showed him the sacral wound. He noted that the sacral wound was open with tissue sloughing and drainage. The LPN also stated that he was surprised to see the condition of the sacral wound because the resident was not bed bound. The LPN stated that there was no prior report that the resident had a skin impairment. The LPN informed the surveyor that there were no physician orders for ointments or medication to apply to the sacral area. There was no evidence that the LPN was aware of preventative barrier cream and/or peri-guard to apply to sacral area. The LPN stated that the santyl ointment was ordered on 1/18/18. On 2/22/18 at 12:04 p.m., the Administrator and the DON met with the survey team. The DON stated that the facility had no answer as to why the barrier cream and the peri-guard were not ordered according to the care plan interventions since February/March 2017. Review of the weekly skin assessments from 1/8/18 through 1/15/18 revealed that the LPN signed the weekly skin assessments in the TAR. There was no documented evidence of a weekly skin assessment by an RN nor was there a co-signature by an RN. According to the New Jersey Board of Nursing Regulations Chapter 37 with a revised date on 1/2/18 regarding Non-Delegable Nursing Tasks indicated that A registered professional nurse shall not delegate the physical, psychological, and social assessment of the patient, which requires professional nursing judgment, intervention, referral, or modification of care. (www.njconsumeraffairs.gov/RegulationsChapter37) On 2/23/18 at 10:18 a.m., the DON informed the survey team that the Charge Nurse (CN) was an RN and failed to perform a body assessment of the resident. Additionally, the DON stated that the CN failed to report the urgency of the unstageable sacral wound. The surveyor was unable to interview the CN due to her resignation during the facility's investigation of the wound. NJAC 8:39-27.1 (e)

Based on observation, interview and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to address the use of a hearing aid for Resident #112. This deficient practice was identified for 1 of 29 residents, Resident #112, reviewed for comprehensive care plans and evidenced by the following: The surveyor reviewed the hybrid medical record on 2/14/18. The quarterly 1/31/18 Minimum Data Set (MDS), an assessment tool, indicated the resident had moderate difficulty hearing - the speaker has to increase volume and speak distinctly (Section B). Additionally, the 1/31/18 MDS indicated that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (Section C). The Audiologist documented in a 9/13/17 Audiology Consult Pt. (patient) is motivated to try left hearing aid. On 9/26/17 the Audiologist documented a new hearing aid was provided to the resident. The surveyor observed Resident #112 on 2/13/18 at 9:56 a.m. and 12:23 p.m.; on 2/14/18 at 10:44 a.m.; and 2/22/18 at 10:35 a.m. The resident was not wearing a hearing at any time during these observations. The surveyor interviewed the resident's regularly assigned Certified Nursing Assistant (CNA) on 02/20/18 at 9:42 a.m. regarding the resident's hearing ability and use of a hearing aid. The CNA stated she had no difficulty communicating with the resident. She further stated the resident did not wear a hearing aid. On 2/13/18 at 9:56 a.m., the surveyor observed Resident #112 seated in a wheelchair at the bedside watching television. The resident stated he/she wears a left hearing aid, however, it was not consistently provided to the resident by the nurse. The resident was not wearing a hearing aid at that time and was having difficulty hearing the surveyor. On 2/13/18 at 12:23 p.m., the resident stated he/she had not been offered the hearing aid by the nurse. The resident further stated it was very important to wear it so that the resident can hear. The care plan addressing a hearing deficit was initiated on 8/3/16 and last revised 2/2/18. The care plan did not reflect to the resident's use of a hearing aid. The surveyor interviewed the Director of Nursing (DON) on 2/22/18 at 12:30 p.m. The DON confirmed the use of a hearing aid had not been in the care plan and indicated the careplan was updated after discussion with the surveyor. The DON provided the surveyor with a copy of the policy for care planning on 2/23/18. The policy was implemented on 12/99 and revised on 11/16. Procedure #13 indicated the team will continue to gather data and develop care plans appropriate to the resident's needs. NJAC 8:39-11.2(e)2 27.1(a)