Every finding on record at Continuing Care at Lantern Hill

Based on observation, interview, and record review it was determined the facility failed to follow standards of clinical practice with regards to ensuring a medication was administered to a resident and not left at the bedside for 1 of 12 residents (Resident #25).This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of 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 1/12/26 at 8:30 AM, the surveyor observed Resident #25 lying in their bed. The resident opened their eyes to the surveyor's greeting and provided no verbal response. The surveyor observed on the resident's bedside table a clear medicine cup which contained apple sauce sprinkled with a white colored pellet (sprinkle) medication.On 1/12/26 at 8:36 AM, the surveyor interviewed Resident #25's assigned Licensed Practical Nurse (LPN) who stated she had not administered any medications to the resident yet on her shift. The surveyor with the LPN reviewed Resident #25's Medication Administration Record (MAR) which revealed the resident received omeprazole capsule (a medication used to reduce stomach acid, which inside contained enteric-coated pellets when opened). The LPN stated a nurse should ensure a medication was taken by a resident and medications should not be left at the resident's bedside.The LPN accompanied the surveyor to Resident #25's room and observed the medication at the resident's bedside. The LPN acknowledged that the medication should not be left at the bedside. The LPN took the medication to be disposed of and stated she would call to inform the physician.On 1/12/26 at 8:39 AM, the surveyor informed the Clinical Manager (CM) of the concern that a medication was found at Resident #25's bedside. The CM acknowledged the concern and stated that all nurses knew they were not to leave medications at the resident's bedside as it was against protocol.On 1/12/26 at 10:40 AM, the surveyor reviewed the Electronic Medical Record (EMR) of Resident #25.The Face Sheet (a summary of important resident information) revealed Resident #25 had diagnoses that included but were not limited to, hemiplegia (a paralysis or severe weakness affecting one side of the body), aphasia (a disorder that affects how you communicate), and heart failure.A Comprehensive Minimum Data Set assessment, a tool used to facilitate management of care, dated 12/12/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #25 scored a 3 out of 15, which indicated the resident had severe cognitive impairment.A physician's order dated 2/22/25 indicated to give omeprazole 40 mg, one capsule by mouth two times a day. The medication was scheduled for 6 AM and 4 PM.A review of the January 2026 Medication Administration Record (MAR) revealed the omeprazole capsule entry was signed by the nurse as administered for the 1/12/26, 6 AM dose.On 1/13/26 at 1:39 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) regarding the concern for the medication observed at Resident #25's bedside. The DON acknowledged the concern, stated that an investigation was initiated immediately, and education would be provided to all staff. There was no additional information provided by the facility.The surveyor reviewed the facility provided policy titled, Medication Administration, Receipt, Storage & Disposal with a version date of October 2023. The policy did not address administering medication to a resident or leaving medications at the bedside. No additional medication administration policy was provided by the facility. The surveyor reviewed the facility provided Medication Administration Observation Checklist, used to evaluate a nurse's competency, which listed the steps of medication administration. Under Standard revealed the steps which included observation of a resident swallowing medications and documentation of a medication administered after its administration. NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to clarify oxygen therapy orders to ensure a resident received respiratory care as ordered by a physician in accordance with professional standards of practice for 1 of 1 resident (Resident #25) reviewed for respiratory care. The deficient practice was evidenced by the following:On 1/12/26 at 8:30 AM, the surveyor observed Resident #25 lying in their bed. The resident opened their eyes to the surveyor's greeting and provided no verbal response. Resident #25 was receiving oxygen via a nasal cannula (NC; plastic prongs attached to a tube inserted into the nostrils that oxygen flows through) which was attached to a concentrator (an oxygen delivery system).On 1/13/26 at 10:13 AM, the surveyor observed Resident #25 lying in their bed. The resident opened their eyes to the surveyor's greeting and provided no verbal response. Resident #25 was receiving oxygen via NC which was attached to a concentrator set at 2 liters per minute (LPM).The surveyor reviewed the Electronic Medical Record (EMR) of Resident #25.The Face Sheet (a summary of important resident information) revealed Resident #25 had diagnoses that included but were not limited to, hemiplegia (a paralysis or severe weakness affecting one side of the body), aphasia (a disorder that affects how you communicate), and heart failure.A Comprehensive Minimum Data Set assessment, a tool used to facilitate management of care, dated 12/12/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #25 scored a 3 out of 15, which indicated the resident had severe cognitive impairment.A physician's order dated 1/6/24 indicated to administer oxygen at 2 LPM for oxygen saturation less than 90% as needed (PRN) by shift.A physician's order dated 12/31/25 indicated oxygen via nasal cannula to keep oxygen saturation above 92%. There was no setting (or LPM) noted on the order. A review of the January 2026 Medication Administration Record (MAR) revealed the PRN oxygen order entry was unsigned as administered and blank for the month of January 2026. A review of the January 2026 Treatment Administration Record (TAR) revealed the order for oxygen via NC, dated 12/31/25 was signed by the nurses. There was no rate of oxygen (LPM) administered to the resident documented.On 1/13/26 at 12:37 PM, the surveyor interviewed Resident #25's assigned Licensed Practical Nurse (LPN) who stated the resident had needed oxygen therapy more recently and was using continuously. The LPN reviewed with the surveyor the resident's oxygen therapy orders. The LPN indicated the order for oxygen via NC dated 12/31/25 was the continuous oxygen order for the resident. The surveyor asked about the LPM of oxygen for the order. The LPN acknowledged the order did not indicate a rate of oxygen to administer and could not speak to why the order did not indicate the LPM.The LPN continued to review the resident's physician orders and identified the PRN order of oxygen for the resident. The surveyor asked if a PRN order should be signed when administered. The LPN replied the nurses documented in the notes if oxygen was administered.On 1/13/26 at 1:39 PM, the surveyor, informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the above concern for Resident #25's oxygen orders. The DON stated she would review to provide a response to the surveyor.On 1/14/26 at 12:04 PM, the LNHA and the DON met with the survey team. The surveyor asked if it was expected for PRN oxygen orders to be signed if administered. The DON replied yes it was. The surveyor reviewed the concern that the PRN order for oxygen was not signed by the nurse as administered and there was no additional oxygen therapy order. The DON stated there was a continuous oxygen order and would provide the TAR to the surveyor.On 1/15/26 at 12:30 PM, the surveyor reviewed with the DON the resident's TAR and the oxygen order entry dated 12/31/25 which no rate of oxygen was indicated. The DON acknowledged the concern that the oxygen order did not have a rate (LPM) for oxygen delivery and the order should have been clarified. There was no additional information provided by the facility. A review of the facility provided policy with the subject of Respiratory Equipment revealed under Procedure, a physician's order was required for respiratory equipment. The policy did not further address physician's orders for oxygen therapy and documentation of oxygen administration. No additional policy for oxygen therapy was provided by the facility. NJAC 8:39-27.1(a)

Complaint #2690327Based on interviews and review of pertinent facility documents on 12/18/25, it was determined that the facility failed to protect a resident (Resident #1) from a significant medication error when the Licensed Practical Nurse, LPN #1, administered intravenous (IV) Zosyn [antibiotic] to Resident #1 and administered IV Meropenem [antibiotic] to Resident #2. Resident #1 had a physician's order for Meropenem 1-gram intravenous solution every eight hours for their heel wound infection [osteomyelitis] and Resident #2 had a physician order for Zosyn 4.5-gram intravenous solution every eight hours for thirty-two days for their wound infection [toe infection]. The Medical Doctor (MD) was notified immediately and ordered to monitor the residents closely. Resident #1 vomited one time at lunchtime, face flushed, felt cold with chills. MD was present and administered IV Benadryl [antihistamine medication for allergic reactions]. Resident #1 was transferred out to hospital emergency room (ER) by 911 [emergency services] and was admitted .On 12/3/25, it was found that LPN #1 administered 6:00 AM dose of IV 1 gram Meropenem to Resident #2 instead of to Resident #1. Also on 12/3/25, it was found that LPN #1 administered 6:00 AM dose of 4.5 gram IV Zosyn to Resident #1 instead of to Resident #2. MD was immediately notified and the residents were closely monitored. Resident #2 was monitored with no adverse effects from one dose of IV medication. Resident #1 was monitored and noted at lunch to vomit one time, face flushed, felt cold with chills. MD administered IV Benadryl and transferred the resident out to hospital for possible side effects of allergic reaction. Resident #1 was admitted to hospital with dx [diagnosis] drug reaction, fever tachycardia (rapid, abnormal heart rate). The facility's failure to protect a resident from a significant medication error placed Resident #1 as well as other residents at risk for significant medication error. This posed the likelihood of serious physical harm injury, or death which resulted in an immediate jeopardy (IJ) situation. The IJ began on 12/3/25 at 6:00 AM when LPN #1 administered the wrong IV antibiotic medications to Residents #1 and Resident #2. The facility's Administration was notified of the IJ on 12/18/25 at 6:00 PM. The facility submitted an acceptable Removal Plan (RP) on 12/19/25 at 6:21 PM. The surveyor verified the implementation of the RP on-site during the continuation of the survey 12/23/25. The deficient practice was evidenced as follows: A review of the facility's policy on Medication Administration, Receipt, Storage & Disposal, version dated 10/2023, included under Procedure: Medication Administration/Assistance .2. Medications are administered in accordance with Nursing Standards of practice and state law; 4. Trained staff designated to administer medications will verify that he/she is administering medications using the 5 Rights of Medication Administration/Assistance and are documented immediately following completion of task for each resident: i) Right resident ii) Right medication iii) Right dose iv) Right time, v) Right route. A review of the Reportable Event Record/Report (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 12/8/25, included the date and time of event: 12/3/25 at 5:30 AM. The FRE further included under Narrative that on 12/3/25, it was found that LPN #1 administered 6:00 AM dose of IV 1-gram Meropenem to Resident #2 instead of Resident #1. Also, on 12/3/25, it was found that LPN #1 administered 6 AM dose of 4.5 gram IV Zosyn to Resident #1 instead of Resident #2 .Resident #1 was monitored and was noted at lunch to vomit one time, face flushed, felt cold with chills. MD administered IV Benadryl and transferred out the resident to hospital for possible side effects of allergic reaction. A review of the facility's Investigation Summary (IS) dated 12/5/25 under Incident Summary: Resident #1 .primary dx includes osteomyelitis .has a physician order for meropenem 1-gram intravenous solution every 8 hours for indication of osteomyelitis of heel. Resident #2 .primary dx includes acute osteomyelitis left ankle and foot .has physician orders for piperacillin-tazobactam [Zosyn] 4.5 gram intravenous solution every 8 hours for 32 days for indication 1st distal [outer/far] phalanx [bone of toe/finger] osteomyelitis [infection]. The IS further indicated on 12/3/25, it was found that LPN #1 administered IV Meropenem to Resident #2 and IV Zosyn to Resident #1. MD immediately notified and residents closely monitored. Resident #2 monitored with no adverse effects. Resident #1 monitored and at lunch vomited x1, face flushed, felt cold with chills. MD administered IV Benadryl .and the resident was transferred out to hospital and was admitted .Resident #1 was discharged from the hospital on [DATE] and returned to facility with new orders for Allergy to PCN [penicillin] and Zosyn .At the time of incident, LPN #1 was immediately educated by the Assistant Director of Nursing (ADON) and was suspended pending investigation. LPN #1 was terminated from employment by LNHA on 12/9/25. A review of the facility's IS included statements from staff. According to the Clinical Manager, Registered Nurse (CMRN), on the morning of 12/3/25, they heard IV pump alarms from their office. The nurse on the floor at the time was busy in another room so they decided to silence the alarms and flush lines for Resident #1 and Resident #2. Both of their IV antibiotics had finished. When the CMRN went to Resident #2's room, they noticed that Resident #1's Meropenem was hung for Resident #2. The Meropenem bag was clearly marked with Resident #1's name, medication name, and dose. Resident #2 appeared to be in good spirits and was not displaying any adverse effects. The CMRN then proceeded to Resident #1's room and discovered that Resident #2's Zosyn had been hung and was finished. This bag was also clearly marked with Resident #2's name, medication, and dose. The CMRN immediately informed LPN #1 who then did a brief assessment and immediately called the doctor for directions and orders. There were no signs of adverse reaction at this point. The CMRN further included in their statement that when hanging IV medications the pump that they used launched a red warning window as the last step in the set-up process. The CMRN stated it would take the nurse to confirm the medication being administered. A review of the statements obtained from LPN #1 dated 12/3/25. According to LPN #1, at around 5:30 AM, a medication error occurred whereby resident was administered the wrong IV medication. LPN #1 stated there were some computer issues and poor lighting and they did not give the med to the right patient. MD on call was promptly notified and instructed to closely monitor the residents. The CMRN and the ADON assisted in resolving the issues surrounding the error, provided education. The residents remained stable and showed no reactions in the immediate hours. Family was notified, PCP [primary care physician] came to follow up and reassessed.A review of the statement made and signed by the ADON. In their statement, the ADON stated they were notified of the medication error with LPN #1 administering the wrong IV antibiotic to two residents. When they interviewed LPN #1, LPN #1 stated that they were setting up IV antibiotics at Nurse Station desk top area. When questioned why, LPN #1 stated that one computer was not working and the other was not charged. LPN #1 said they prepared both residents' IV antibiotics and hung the IV infusions. The CMRN later informed the ADON that when they were going to silence the alarm from pump alerting completion of infusion to find the wrong antibiotic was hung for the two residents. The ADON further said that the CMRN that the physician was called immediately to monitor both residents . Resident #1 was transferred to hospital and admitted with dx [diagnosis] Drug reaction, fever, tachycardia. ADON further included in their statement that LPN #1 did not follow medication administration and Nursing Standard of Practice for the following three checks and 5 rights. The ADON stated they did med pass [medication pass] to LPN #1 to determine competency medication administration. ADON said that when started med pass with LPN #1, the LPN stated they was having problem with laptop LHN-L-10032318 (Laptop 1) again. Laptop was exchanged for another laptop with no problems. The ADON brought Laptop 1back to cart and completed med pass with LPN #1. The ADON stated the employee were educated in medication administration. Medication Administration Observation completed. Educated and reviewed triaged problems with computers and kept laptop charged at all times with all nurse. The surveyor reviewed the medical record for Resident #1. A review of the Face Sheet (FS), an admission record summary, revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to: osteomyelitis [infection of the bone], pressure ulcer [open area] of right heel, stage 3; pressure ulcer of left heel, stage 3; stiffness of left knee; atrial fibrillation [abnormal heart rate]; hypertension, and age-related osteoporosis [thinning and weakening of the bones due to aging]. A review of the Minimum Data Set (MDS), an assessment tool dated 10/24/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which reflected an intact cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs). The resident's MDS further revealed in Section N-Medications, under N0415. High-Risk Drug Classes: Use and Indication, that the resident was taking .F. Antibiotic and an Indication was noted. A review of Resident #1's individual Holistic Care Plan (HCP) under 10. Medications which included a Goal: The nurse and/or caregiver will administer my medications as prescribed and monitor for side effects .I will not experience any complications as a result of medication administration, and Care Plan Approaches which included but not limited to: I will not have complications related to my medication regimen .A review of the resident's Clinical Notes Report (CNR) with effective date entered as 12/03/2025 at 7:00 AM, authored and e-signed [electronically signed] by LPN #1. The CNR revealed LPN #1 documented .At 5:30am there were issues with computers Zosyn was inadvertently administered in lieu of Meropenem, as the 3 steps check could not be applied effectively. Upon notification of error, on call MD [name redacted] was promptly notified. Patient history was reviewed with MD and no order was given. Resident was closely monitored with frequent vital signs and close monitoring. Spoke with daughter [resident's ][name redacted] and made her aware. Endorsed to incoming nurse to follow up . A review of Resident #1's Medication Administration Record (MAR) titled December 2025 Medications indicated an entry order of meropenem 1 gram intravenous solution (1gram) VIAL Intravenous; Every Eight Hours for Four Weeks Starting 11/07/2025 Order ID: 4000266 with Order Date: 11/7/2025; Discontinued (12/03/2025); Notes: Indication: Osteomyelitis. The MAR revealed under Schedule of 6:00 am and column 03 [stands for date 12/03] showed LPN #1 initial of [redacted] indicating the nurse administered the medication. The surveyor reviewed the medical record for Resident #2.A review of the Face Sheet (FS), an admission record summary, revealed that Resident #2 was admitted to the facility with diagnoses which included but were not limited to: acute osteomyelitis, left ankle and foot; effusion right knee; syncope and collapse; pneumonia; gastrointestinal hemorrhage; congestive heart failure; essential (primary) hypertension; atrial fibrillation; chronic kidney disease, and metabolic encephalopathy.A review of the Minimum Data Set (MDS), an assessment tool dated 11/18/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which reflected the resident's cognition was moderately impaired. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs). The resident's MDS further revealed in Section N-Medications, under N0415. High-Risk Drug Classes: Use and Indication, that the resident was taking .F. Antibiotic and an Indication was noted. A review of Resident #2's individual HCP under 10. Medications which included a Goal and Care Plan Approaches which included but not limited to: The nurse and/or caregiver will administer my medications as prescribed and monitor for side effects daily.A review of Resident #2's Medication Administration Record (MAR) titled December 2025 Medications indicated an entry order of piperacillin-tazobactam (Zosyn) 4.5 gram intravenous solution (4.5 gm/100ml) VIAL Intravenous; Every Eight Hours for Thirty-Two Days Starting 11/13/2025 Order ID: 4005870 with Order Date:11/13/2025; Discontinued (12/03/2025); Notes: Indication: 1st distal phalanx osteomyelitis. The MAR revealed under Schedule of 6:00 am and column 03 [stands for date 12/03] showed LPN #1 initial of [redacted] indicating the nurse administered the medication. On 12/18/25 at 2:52 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA). The DON stated LPN #1 did not follow the facility's medication administration procedure. The DON further stated the LPN was hired around four months ago and passed her medication administration pass competencies with both the ADON and the pharmacist consultant (PC), attended the education in-services as required. DON said that when they knew of the incident on medication error on 12/3/25 with the two residents, the LPN was educated on medication administration competency.The LNHA stated LPN #1 was suspended pending investigation and was eventually terminated on 12/9/25. The DON stated LPN #1 did not follow the medication pass protocol and procedure despite education in-services that were done with her by the facility. A Removal Plan (RP) was submitted by the facility on 12/19/25 at 6:21 PM indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: On 12/3/25, LPN #1 was found to administer the incorrect IV antibiotic medications to Resident #1 and Resident #2; MD was notified immediately and both residents were closely monitored; 12/3/25 at lunchtime, Resident #1 vomited one time, face flushed and felt cold with chills, MD at bedside and the resident was transferred to the ER; Resident #2 had no adverse reactions to the medication error; on 12/3/25, nurse medication administration observation checklist was completed and LPN #1 demonstrated competency immediately after medication error was found; LPN #1 was suspended on 12/3/25 and terminated on 12/9/25; on 12/3/25, a 100% audit of all current residents that have physician order of IV antibiotics were reviewed by the assistant director of nursing (ADON) to validate the correct IV antibiotics orders and that IV medications were in the medication room; medication administration education began on 12/3/25 and IV competencies began for all nurses - all nursing staff must complete education and competencies before their next scheduled shift; all newly hired nurses will be educated on proper medication administration including return demonstration during orientation; on 12/4/25 a new process was created requiring two nurses to verify the correct IV medication before administering to residents, and random audits were being conducted monitoring nurses who were administering IVs started on 12/4/25. The surveyor verified the implementation of the RP on-site during the continuation of the survey on 12/23/25. NJAC 8:39-29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included the use splints (medical device that stabilizes a part of your body and holds it in place); a CP that included the use of anticoagulants (AC), and a CP that included pressure ulcer care. This deficient practice was identified for 5 of 15 residents (Resident #3, #5, #17, #11, and #29) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: 1. On 9/9/24 at 09:28 AM, the surveyor observed Resident #3 awake in bed. The surveyor also observed the resident had a left arm and left hand contracture. Resident #3 stated they wear a splint in the evening and the splint is removed in the morning. The surveyor reviewed Resident #3's medical records, which revealed that the resident was admitted to the facility with diagnoses that included but not limited to Hemiplegia (a condition characterized by paralysis of one side of the body) affecting left non-dominant side; Contracture left hand and muscle weakness. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/5/24 revealed a Brief Interview for Mental Status (BIMS) that could not be completed at the time of interview. The Quarterly MDS further revealed Resident #3 had been using a splint. A review of the August 2024 Physician Order Sheet revealed a Physician's Order (PO) dated 2/7/24, for Splint/Brace, apply onto left hand/arm in HS (bedtime) and remove in AM (morning). A review of the CP titled Holistic Care Plan/Continuing Services with a start date of 1/6/24 and a last reviewed date of 7/3/24, did not reflect the resident's use of the left hand/arm splint/brace. On 9/10/24 at 9:55 AM, the surveyor conducted an interview with Licensed Practical Nursing (LPN#1) who stated the residents CP are kept in a separate notebook inside the resident's room. LPN #1 added that the use of hand splint must be addressed in the resident's CP. LPN #1 was not able to locate a CP for Resident #3's use of splint/brace and could provide any information as to why there was no care plan initiated. 2. On 9/9/24 at 10:47 AM, the surveyor observed Resident #17 in their room with eyes closed in bed. The surveyor reviewed Resident #17's medical records which revealed that the resident was admitted to the facility with diagnoses that included but were not limited to Nontraumatic intracerebral hemorrhage; Acute Embolism and thrombosis of the right femoral vein; and Atrial Fibrillation. A review of the Quarterly MDS, dated [DATE] revealed a BIMS score of 5 out of 15, which indicated that the resident had severely impaired cognition. The MDS further revealed under Section N. Medications that Resident #17 was taking an AC medication. A review of the September 2024 POS revealed a PO dated 12/22/23, Eliquis 2.5 milligram (mg) tablet (1 tab) Tablet oral. A review of Resident #17's CP which reflected a review date of 9/6/24, revealed under the medication's portion which did not reflect the resident's use of AC medication. 37791 3. On 09/09/24 at 9:59 AM, the surveyor observed the resident who was seated in a wheelchair in the dining room, eating breakfast with other residents. The surveyor reviewed Resident #5's medical records, which revealed that the resident was admitted to the facility with diagnoses that included but not limited to Hypertension (a condition in which the force of the blood against the artery walls is too high); Hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood); Hemiplegia following cerebral infarction (a condition that causes paralysis on one side of the body and is common result of a stroke and cerebral infarction); and Diabetes Mellitus (is a disorder in which the amount of sugar in the blood is elevated). A review of the Admission MDS dated [DATE], reflected the resident had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. A review of the September 2024 POS revealed a PO dated 8/19/24 for Foam Boots to be applied at HS (bedtime) and removed in the morning. The September 2024 POS also reflected that Resident #5 had a PO dated 9/5/24 for soft splint to be applied to left hand at HS and removed in AM. A review of the comprehensive person-centered CP for Resident #5 did not reflect the resident's use of foam boots and splint to their left hand. On 9/11/24 at 11:15 AM, the surveyor requested documentation for Resident #5 from the Director of Nursing (DON). The surveyor informed the DON that the resident's foam boots, and splint did not reflect in the resident's CP. The DON told the surveyor that she was aware of the concern. 37175 4. On 09/10/24 at 11:54 AM, the surveyor observed Resident #29 in bed with a family member present at bed side. The resident was alert and stated that they had pressure wounds. The surveyor reviewed Resident #29's medical records, which revealed that the resident was admitted to the facility with diagnoses that included but not limited to Cerebral Infarction (lack of blow flow in the brain), Hemiplegia (paralysis on one side of the body), and Malignant Neoplasm (cancer) of urinary organ. A review of the Quarterly MDS, dated [DATE], revealed that the resident had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Further review of the MDS revealed the resident had a stage 4 pressure ulcer (PU) and 2 different sites of unstageable PU's. A review of the September 2024 POS revealed a PO dated 08/29/24 for antibacterial foam wound dressing 4x4 bandage with an indication for the left heel pressure injury to cleanse with normal saline, apply the antibacterial foam wound dressing soaked in sterile water then cover with a foam island dressing. Further review of the September 2024 POS revealed a PO dated 08/29/24 for 4x4 bandage with an indication for the right heel pressure injury to cleanse with normal saline, apply antibacterial foam wound dressing soaked in sterile water then cover with a foam island dressing. A review of Resident #29's CP titled Holistic Care Plan did not reflect a CP that addressed the resident's right heel and left heel PU's. On 09/12/24 at 09:56 AM, the surveyor interviewed and reviewed the CP's that were provided by the DON, who stated to the surveyor the CP's that were provided were the residents CP's and there were no CP's for the pressure wounds that had developed. A review of the facility's policy titled Skin Integrity Program dated 01/24 revealed that if a new wound is identified during skin checks the care/service plan will address approaches for wound care. 46889 5. On 9/09/24 at 10:13 AM, the surveyor observed Resident #11 seated in their wheelchair inside the main dining room. The resident was able to answer the surveyor's inquiry and stated they were not in any pain. The surveyor reviewed Resident #11's medical records, which revealed that the resident was admitted to the facility with diagnoses that included but not limited to Atrial Fibrillation (irregular heartbeat). A review of the Quarterly MDS, dated [DATE], revealed that the resident had a BIMS score of 3 out of 15, indicating severely impaired cognition. Further review of the MDS under Section N. Medications indicated that the resident was taking AC. A review of the form titled, August 2024 Medications for Resident #11 reflected a PO for Eliquis 2.5 mg (milligram) tablet (1 tab) tablet oral two times daily started on 8/10/24. A review of Resident #11's CP which reflected an initiated date of 9/9/24, revealed under the medication's portion which did not reflect the resident's use of AC medication. On 9/10/24 at 9:59 AM, the survey team interviewed the DON, who stated holistic assessment included the CP. The DON further stated that the CP were kept in a notebook inside each resident's room. The DON added that the CP's were updated as needed and for any immediacy on the CP's would be handwritten. The DON agreed that the hand splints; use of AC medications; PU's and pressure relieving devices must be addressed in the CP. The DON did not provide any further information as to why the above concerns were not reflected in each of the resident's CP's. On 9/10/24 at 11:30 AM, the DON provided the survey team with a facility policy, Care/Service Plans with a revision date of 5/2021. Under the procedure section of the policy it states, 1. Guest/residents admitted to Post Acute/Long Term Care will have .b, The interim care plan will reflect the resident's goals and include interventions that address his or her current needs .c. The interim care plan will include healthcare information necessary to care for resident including, but not limited to .ii. Physician orders (list of medications) 4. Any changes identified in the comprehensive care plan in the resident's goals, physical, mental, or psychosocial function, that was not identified in the interim care plan will be provided in to the resident and/or responsible party .8. Care plans will be reviewed, revised if applicable, on an ongoing basis by the interdisciplinary team with any changes in condition and after each assessment, including both comprehensive and quarterly review assessments. On 9/11/24 at 2:00 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. There were no further information provided. NJAC 8:39-11.2(e)(2) thru (i); 27.1(a), (d)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 9/9/24 at 8:29 AM, the surveyor in the presence of the General Manager of Dining Services (GMDS) observed the following during the kitchen tour: 1. In the walk-in refrigerator, the surveyor observed a 2 gallon container with Bechamel sauce with a use by date of 9/8/24, cooked bacon with a use by date of 9/7/24, a full tray pan of shrimp defrosting not covered or labeled, a 1 gallon tub of an unidentified white liquid with no date, and a full sheet pan of raw asparagus not labeled. The GMDS stated all items were past the use by date and should have been discarded by the evening supervisor. The GMDS also confirmed that all items need to be labeled with prepared date and use by dates. 2. In the walk-in freezer, the surveyor observed multiple items stored higher than 18 inches from the ceiling. 3. In the dry storage area, the surveyor observed an open bag of sourdough bread with a use by date 9/7/24, an open bag of 160 ounce (oz) pasta not properly wrapped or labeled, and a 1 gallon container Worcestershire 8/14/24 use by date. The GMDS stated all items were past the use by date and should have been discarded by the evening supervisor and all items need to be labeled with open and use by dates. 4. In the cooking area of the kitchen, the surveyor observed the two, two door standing ovens. The inside of oven #2 had black colored cooked on debris and oven #1 had a sticky white colored substance on lower oven door handles. On 9/9/24 at 9:12 AM, the surveyor while on dining observations observed the following: 5. Surveyor observed an open container of cranberry juice labeled with a use by date of 9/8/24. The dietary aide (DA#1) stated that the cranberry juice should have been discarded. DA#1 could not provide any information on how the cranberry juice was in the dining room. On 9/10/24 at 9:50 AM, the GMDS provided the surveyor with three facility policies: Labeling and Dating with a revised date of 4/2024, Cleaning and Sanitizing Major Cooking Equipment with a revised date of 1/2024, and Food/Non-Food Storage with a revised date of 4/2024. The labeling and dating policy states under the procedure section, 2. All items will have a received date. 3. All opened items or items not in original containers will be covered, clearly and properly labeled. 4. Leftover food will be in appropriate containers or wrapped and dated. Leftover food is checked daily to determine its usage. If it cannot be used within 72 hours of production, it is labeled, dated, and frozen for future use. The cleaning and sanitizing major cooking equipment policy states under the procedure section, 1. All Food Service Equipment and preparation Equipment will be cleaned and sanitized after each use and maintained in a clean and sanitized condition. The food/non-food storage policy states under its procedure section, 3. All food and supplies will be stored six (6) inches above the floor, and 18 inches from the ceiling. On 9/10/24 at 1:49 PM, the survey team met with the Licensed Nursing Home Administrator (LHNA) and Director of Nursing to discuss the above concerns. There were no further information provided. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to maintain the nursing professional standard of clinical practices by not accurately 1. documenting the pain management assessment and 2. Documenting the time and use of each as-needed (PRN) pain medication for 1 of 12 residents (Resident #11) reviewed for unnecessary medications. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 9/09/24, at 10:13 AM, the surveyor observed Resident #11 seated in their wheelchair in the main dining room. The resident was able to answer the surveyor's inquiry and stated that they were not in pain. On 9/11/24, at 10:42 AM, the surveyor reviewed Resident #11's electronic medical record and revealed the following information: According to the Admission Record (an admission summary), Resident #11 was admitted to the facility with diagnoses that included but were not limited to left closed Femur fracture with routine healing. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored 3 out of 15, which indicates that resident had severe cognitive impairment. Further review of the MDS under Section J. Pain Management Pain Presence was answered as 0. No. A review of Resident #11's August 2024 Medications revealed the following Physician Orders: Acetaminophen 325 mg tablet (2 tablets = 650 mg) oral PRN every 6 (six) hours. Notes: Indication: Pain, with an order date of 8/09/24. Tramadol 100 mg tablet two (2) times daily. Notes: Indication: Pain management Give (1) tablet PO BID (twice daily). with an order date of 8/28/24. Further review of the form titled August 2024 Medications reflected a medication with an order date of 8/20/24 for Tramadol 100 mg 1 tablet as needed every six hours that were administered on the following dates: 8/16/24 at 20:00 8/21/24 at 08:02 8/23/24 at 08:21 8/24/24 at 13:04 8/25/24 at 07:40 8/26/24 at 09:46 The surveyor could not locate in the medical records regarding any pain assessment documentation before and after the pain medication was administered to the resident. A further review of the clinical notes from August 9 through August 28, 2024, did not reflect any documented pain assessment; the time when the medication was administered and the indication of use for Tylenol 650 mg every 6 hours PRN. A review of the form titled Holistic Care Plan initiated on 9/09/24 revealed under 6. Pain, under Goal(s), which revealed to, Please monitor for action and expression of pain as well as asked. On 09/11/24, at 09:35 AM, the surveyor interviewed the Certified Nursing Assistant who stated that when the resident complained of pain, they would report it to the nurse. On 09/11/24 at 9:45 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that Resident #11's medical record had no pain assessment monitoring that was ordered by the Physician. On 9/11/24 at 01:50 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON stated that the nursing staff does not complete any pain assessment documentation. A review of the policy titled Pain Management, updated in May 2021 under Procedure: revealed that 3. Nurse uses the numerical Pain Intensity Scale and/or physical observations to identify the presence of pain, 5. Nurse will notify provider of existing pain and/or history of pain presently relieved or not relieved by medications and non-medicinal approaches, and 7. Pain level will be assessed before and after administration of analgesic and documented in the Physical Monitors in the eMAR. There were no further information provided by the LNHA and the DON regarding the concern above. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to maintain adequate infection control practices during a) food service in the kitchen for 3 of 3 staff observed performing hand hygiene and b) dining services for 2 of 2 staff observed performing hand hygiene. This deficient practice was evidenced by the following: 1.) On 11/26/19 at 9:09 AM, during the initial tour of the kitchen, the surveyor observed the General Manager turn on the faucet, apply soap to her hands and immediately rinse her hands under running water for 16 seconds. On that same day at 12:38 PM, during observation of the tray line in the kitchen, the surveyor observed the Executive Chef wash his hands and turn off the faucet with the same paper towel he used to dry his hands. On that same day at 12:47 PM, the surveyor observed the Dining Wait Staff Member turn on the faucet and without applying soap, immediately put her hands under running water for 4 seconds. On that same day at 12:54 PM, the surveyor observed the General Manager turned on the faucet, apply soap to her hands and immediately rinse her hands under running water. On that same day at 12:57 PM, the surveyor interviewed the Dining Wait Staff, who stated that she should have applied soap to her hands and washed them for 60 seconds. On that same day at 1:00 PM, the surveyor interviewed the Executive Chef, who stated that he wasn't aware that he should have used a clean paper towel to turn off the faucet. The surveyor asked the Executive Chef what the Facility's Policy and Procedure instructed. The Executive Chef stated that he was not sure. On that same day and time, the General Manager acknowledged that after she applied the soap to her hands, she should have lathered and used friction outside of the running water for at least 20 seconds. 2.) On 11/26/19 at 11:51 AM, during the lunch meal in the skilled nursing dining room, the surveyor observed that the Dining Manager turned on the faucet, applied soap to her hands, and immediately rinsed her hands under running water. The Dining Manager dried her hands with a paper towel and then used the same paper towel to turn off the faucet. On that same day at 12:18 PM, the surveyor observed that the Dining Associate turned on the faucet, applied soap to her hands, and immediately rinsed them under running water. The Dining Associate then donned a pair of gloves, served a plate of food, removed the gloves, turned on the faucet, applied soap to her hands, and again immediately rinsed her hands under running water. On that same day at 12:27 PM, the surveyor observed the Dining Manager remove her gloves. She did not perform hand hygiene. On that same day at 12:33 PM, the surveyor observed the Dining Associate turn on the faucet, apply soap to her hands, and wash her hands for 12 seconds. On that same day at 1:13 PM, the Dining Manager acknowledged that she should have washed her hands after she removed her gloves and should have washed her hands for 20 seconds outside of the running water. She further stated, why can't I turn off the faucet with the same paper towel that I used to dry my hands? The surveyor asked the Dining manager what the facility's policy and procedure was. The Dining Manager replied, I don't know. On that same day at 1:20 PM, the surveyor observed the Dining Associate turn on the faucet and without wetting her hands with water, apply soap and washed her hands for only 5 seconds. On that same day and time, the surveyor interviewed the Dining Associate who acknowledged that she should have washed her hands for 20 seconds and should have washed her hands after removing gloves. The surveyor reviewed the facility's Sanitary Inspection Report dated 8/23/19, which reflected that the facility was out of compliance with proper Handwashing. The surveyor reviewed the Facility's Policy on Hand Hygiene-Standard Operating Procedure dated 5/2019 which reflected to perform hand hygiene after the removal of Personal Protective Equipment (PPE). It further reflected: Procedure/Technique for hand washing with soap and water: The CDC Guidelines for Hand Hygiene in Healthcare Settings recommends: 1. wet your hands first with water 2. apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers 3. rinse your hands with water 4. use disposable towels to dry 5. use towel to turn off the faucet. On 11/26/19 at 2:15 PM, the surveyor discussed the above observations and concerns with the Administrator. On 11/27/19 at 11:00 AM, no further information was provided by the facility. NJAC 8:39-19.4 (n)

Based on observation and interview of facility staff it was determined that the facility failed to ensure the daily posting of nurse and certified nurse assistant (CNA) staffing and resident census was posted at the beginning of the current shift. This deficient practice was observed on 2 days (2/11/19 and 2/13/19) of the 2 day long inspection and was evidenced by the following: On 2/11/19 at 8:30 a.m., the surveyor entered the facility and observed the Nursing Home Resident Care Staffing Report posted in the entryway to the facility. The report was dated 2/8/19, 3 days prior. On 2/13/19 at 11:05 a.m., the staffing report was posted in the entryway of the facility, dated 2/12/19, the previous day. On 02/13/19 at 11:10 a.m., the surveyor interviewed the Director of Nursing (DON) regarding the concern that the posting was not current on 2/11/19 and 2/13/19. The DON stated the scheduling person was off for the weekend. She stated there was no other staff person assigned to post staffing on weekends. On 2/13/19 at 1:22 p.m., the surveyor interviewed the Administrator and the DON. Neither was aware that staffing must be posted on a daily basis at the beginning of each shift. On 2/13/19 at 1:40 p.m., the surveyor interviewed the Nurse Scheduler. She stated she usually posted the day's staffing, after updating, in the middle of the day. She further stated, staffing is not posted on weekends. There was no additional information provided. NJAC 8:39-41.2

Based on observation, interview and record review, it was determined that the facility failed to properly dispose and label medication for 1 of 1 medication storage inspected. This deficient practice was evidenced by the following: On 2/11/19 at 08:49 a.m., the surveyor inspected the Nursing unit medication room refrigerator in the presence of a Registered Nurse/Unit Manager (RN/UM). The surveyor observed an opened and undated as to the date opened C-[MEDICATION NAME] suspension bottle with 75 milliliters (ml) of the medication remaining inside the bottle. In addition, the surveyor observed a total of eight 50 ml Intravenous (IV) bags of [MEDICATION NAME] antibiotic medication. The RN/UM informed the surveyor that the IV antibiotic medication was for Resident #236 who was discharged on [DATE]. On that same day and time, the RN/UM informed the surveyor that the C-[MEDICATION NAME] suspension should have been dated. She stated that the IV antibiotic medication for Resident #236 should have been removed from the refrigerator on the same day that the resident was discharged per facility policy. She further stated that IV medications cannot be returned to the pharmacy and had to be discarded. On 2/13/19 at 10:41 a.m., the surveyor met with the Administrator and the Director of Nursing (DON) and discussed the above observations and concerns. A review of the facility's Policy titled Medication Administration, Receipt, Storage and Disposal provided by the DON dated 9/6/18 indicated that When permitted by State or local law, medications of residents who are transferred or discharged from the continuing care residence will be returned to the pharmacy unless the provider orders the medication(s) and controlled substance(s) be sent with the resident. NJAC 8:39-29.4 (a) (h) (d)

Based on observation, interview and record review, it was determined that the facility failed to store potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 2/11/19 at 9:16 a.m., in the presence of the Dietary General Manager and the Administrator, the surveyor observed the following inside the walk-in refrigerator: 1. There were three unopened packs of pork tenderloin on a sheet pan dated 2/7/19 and a use by date of 2/10/19. The general manager stated, I don't know why the meat wasn't used. The general manager discarded all three packages of the pork tenderloin in the presence of the surveyor. 2. There was a one package of beef unopened on a sheet pan with no pull date and no use by date. The general manager said she didn't know when the package of beef was pulled and she discarded the beef in the presence of the surveyor. 3. There were two small metal pans of sliced tomatoes covered with saran wrap undated and no use by date. The general manager said they should have been dated. 4. There was an opened package of pork roll wrapped in saran wrap on a sheet pan dated 2/2/19 with a use by date of 2/9/19. The general manager said it should have discarded and she discarded the pork roll in the presence of the surveyor. On that same day the surveyor observed the following inside the dry storage room: 5. The rice and bread crumb bins had no dates. The general manager said both the rice and bread crumb bins should have dates. On that same day the surveyor observed the following inside the reach-in freezer: 6. There were 10 vegetable patties inside a plastic bag and there were three vegetable patties outside of the plastic bag laying on the bottom of the plastic bin open to the air. The package of the vegetable patties were dated 1/1/19 with a use by date of 2/1/19. The general manager said they should have been discarded and she discarded the vegetable patties in the presence of the surveyor. Review of the facility's policy for Food Labeling and Dating dated 4/2016 provided by the Administrator indicated in procedure #2 that all opened items or items not in original containers will be covered, clearly labeled, and dated. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to a.) adhere to accepted standards of infection control practices for the proper storage of respiratory tubing and mask after use. This deficient practice occurred for 1 of 2 residents, Resident #14; and to b.) use the required personal protective equipment (PPE) and perform hand washing to prevent the spread of infection on a resident with transmission based precautions. This deficient practice occurred for 1 of 2 residents, Resident #12. This deficient practice was evidenced by the following: 1. During the initial tour on 1/3/18 at 10:04 a.m., the surveyor observed Resident #14 in his/her bedroom seated in a wheelchair while watching television. The hospice aide was seated at the bedside. The surveyor observed the nebulizer mask directly touching the nebulizer machine surface on top of the night stand and oxygen tubing directly touching the surface of an oxygen concentrator. The medical record reflected Resident #14 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The medical record also revealed that the resident was admitted to hospice care on 11/2/17. On 1/5/18 at 10:40 a.m. and 10:42 a.m., the surveyor observed Resident #14's bare oxygen tubing and nasal cannula directly touching the floor. At 10:40 a.m. and 10:42 a.m., the surveyor observed the Unit Secretary and the Registered Nurse/Clinical Manager (RN/CM) come out of resident's room. The resident was seated at the edge of the bed during the 10:40 and 10:42 a.m. On the same day at 12:11 p.m., the surveyor observed that the resident was not in the room. At that time, the surveyor observed that the oxygen nasal tubing was directly touching the oxygen concentrator. A review of the medical record revealed the following orders for Resident #14 on January 2018 Physician order [REDACTED]. On 1/9/18 at 8:59 a.m., the surveyor and the RN/CM went to the resident's room. The surveyor showed to RN/CM the spirometer with attached pipe tubing, oxygen tubing and nebulizer mask directly touching surfaces of the table and cabinet. The RN/CM stated that the respiratory tubing and nebulizer mask should have been placed inside a plastic bag when not in use as a standard of practice to prevent infection. On 1/10/18 at 9:15 a.m., the Director of Nursing provided a facility policy for Respiratory Equipment with a version date of 6/2014 which indicated, Nebulizer tubing will be kept in a plastic bag when not in use, and Oxygen tubing, when not in use, will be placed in a plastic bag and kept off the floor. 2. During the initial tour on 1/3/18 at 10:31 a.m., the surveyor observed Resident #12 in the bedroom with a STOP sign and personal protective equipment (PPE) cabinet outside the room. On the same day at 11:04 a.m., the surveyor interviewed the RN/CM who stated that the Resident #12 was currently on antibiotic therapy for [MEDICAL CONDITION]-resistant Staphylococcus Aureus (MRSA) (a bacterium that causes infections in different parts of the body). The resident was on contact isolation due [MEDICAL CONDITION] in the urine. The RN/CM informed the surveyor that staff need to use gown and gloves when entering the room to prevent the spread of infection. On 1/5/18 at 9:03 a.m., the surveyor observed that the Certified Nursing Assistant (CNA) did not use a gown and gloves when entering the resident's room. While in the room, the CNA adjusted the bed of Resident #12 without applying gloves. The CNA then left the room without performing hand washing. The surveyor interviewed the CNA. The CNA stated that the resident was on contact precautions due to an infection in the blood and urine. The CNA informed the surveyor that staff only use gloves and gown when performing direct care. The CNA stated, in the presence of another surveyor, that staff does not need to gown and glove when no direct resident care is done. On 1/5/18 at 10:55 a.m., the surveyor interviewed the resident. The resident stated that he/she was on isolation because of an infection in the blood and urine. The resident informed the surveyor that staff at times comes in and out of the room without gowning and gloving. On 1/5/18 at 12:09 p.m., the surveyor reviewed the resident's medical record. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record contained a Universal Transfer Form dated 12/18/17 noting the resident was transferred to the facility on isolation precautions due [MEDICAL CONDITION]. Further review of the medical record revealed there was a physician's orders [REDACTED]. On 1/11/18 at 9:31 a.m., the Director of Nursing (DON), in the presence of the survey team and the facility administrator, stated that the CNA was educated regarding infection control with use of PPE and hand washing. The DON informed the survey team that the CNA admitted to not wearing a gloves or a gown and to not hand washing on 1/5/18 when he/she adjusted the bed of the resident and then left the room. On 1/10/18 at 9:15 a.m., the DON provided a facility policy for Infection Prevention & Control: Standard and Transmission Based Precautions with a version date of 11/14/2017 which indicated, Hands are washed immediately after exposure or possible exposure to infectious materials or sources of potentially infectious materials. Common times at which hands need to be washed include: after leaving an isolated area or after handling articles from an isolated area, and Contact Precautions: Gown, gloves and handwashing, in addition to wearing gloves as outlined under Standard Precautions, wear gloves and gown when entering the room. NJAC 8:39-19.4 (a) (1, 2)

Based on interview and record review, it was determined that the facility failed to develop and implement a baseline care plan for the resident within 48 hours of admission. This deficient practice occurred for 1 resident, #12, of 16 residents reviewed. This deficient practice was evidenced by the following: During the initial tour on 1/3/18 at 10:31 a.m., the surveyor observed Resident #12 in his/her room bedroom with a STOP sign and personal protective equipment (PPE) cabinet outside the room. On the same day at 11:04 a.m., the surveyor interviewed the Registered Nurse/Clinical Manager (RN/CM). The RN/CM stated that Resident #12 was currently on antibiotic therapy for [MEDICAL CONDITION]-resistant Staphylococcus Aureus (MRSA) (a bacterium that cause infections in different parts of the body) and was currently on contact isolation due [MEDICAL CONDITION] in the urine. The RN/CM informed the surveyor that staff had to use gown and gloves when entering the room to prevent the spread of infection. On 1/5/18 at 12:09 p.m., the surveyor reviewed the medical record for Resident #12. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record contained a Universal Transfer Form dated 12/18/17 that noted the resident was transferred to the facility with isolation precautions due [MEDICAL CONDITION]. A review of Resident #12's medical record provided by the facility on 1/5/17 at 12:16 p.m. revealed that there was no baseline care plan initiated within 48 hours of admission on 12/18/17. Further review of the resident's care plan revealed that the UTI and isolation precautions, due [MEDICAL CONDITION], was not initiated until 12/25/17. On 1/11/18 at 9:31 a.m., the Director of Nursing (DON) stated that the resident was admitted to the facility on [DATE]. The DON also stated that the baseline care plan was not initiated until 12/25/17. On 1/10/18 at 9:15 a.m., the DON provided a facility policy for Care/Service Plans with a version date of 11/28/17 which indicated, A baseline care plan generated by nurse within 24 hours of admission, and The baseline care plan will reflect resident's goals and include interventions that address his or her current needs in a language and format that the resident and/or representative, if applicable, understand. NJAC 8:39-11.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to document the code status on the medical record for 2 residents, #169 and #170, of 12 reviewed. This deficient practice was evidenced by: 1. Resident #170 was admitted to the facility on [DATE] following hospitalization for hip surgery. The surveyor observed the resident in bed on 1/3/18 at 12:15 p.m. with family members at the bedside. The resident was alert and conversant. The resident preferred not to be interviewed by the surveyor. The surveyor reviewed the hybrid medical record (electronic and paper) on 1/8/18. The surveyor did not locate an advanced directive on the record. The 12/26/17 Advanced Directives and End of Life Care care plan did not indicate the code status of the resident. The January 2018 Physician order [REDACTED]. The following blank forms were on the medical record: Medical Society of NJ Do Not Resuscitate, NJ Practitioner Orders for Life-Sustaining Treatment (POLST), Surrogate Decision Maker. The surveyor interviewed the Social Worker on 01/08/18 at 11:57 a.m. regarding the resident's advanced directive and code status. The Social Worker stated the care plan meeting was scheduled for the following day with the family. She further stated the code status would be updated the following day after the code status/advance directive was discussed. During the same interview, the surveyor asked the Social Worker what would happen if the resident became unresponsive in the facility. The Social Worker replied, I see what you mean. The surveyor requested documentation of code status after the meeting was conducted with the resident. The code status of the resident was not provided to the surveyor. 2. On 1/03/18 at 12:28 p.m., the surveyor reviewed Resident # 169's Electronic Medical Record (EMR). There was no advance directive or code status in the EMR. Review of the admission record reflected Resident #169 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. On 1/08/18 at 12:09 p.m., the surveyor reviewed the paper chart of Resident #169 and the following blank forms were on the medical record: POLST form and Code Status Discussion form. The surveyor then reviewed the 12/22/17 admission Physician order [REDACTED].#169 in either the EMR or the paper chart. On 1/08/18 at 12:25 p.m., the surveyor asked Resident #169's Certified Nursing Assistant (CNA) how do you know the residents code status? The CNA said, I would look in the care plan to get his/her code status. At that same time, the CNA along with the surveyor reviewed the residents care plan which did not reveal a code status. The CNA then stated I know his/her code status because he/she has a purple DNR (Do Not Resuscitate) bracelet on. At that same time, the CNA then showed the surveyor the residents bracelet which was on the residents left wrist. At that time the administrator told the surveyor that the bracelet is from the hospital and should have been be cut off. The administer further said the residents of the facility do not wear those bracelets. On 1/08/18 at 12:30 p.m., the Registered Nurse/Staff Development Coordinator (RN/SDC) along with the surveyor reviewed Resident #169's paper chart. The RN confirmed that the code status of the resident and the advance directive were not in the electronic or paper chart. The RN also reviewed the resident's admission orders [REDACTED]. The RN further stated that the social worker is the one who audits the charts to ensure the residents advance directives/code status are in the chart. The surveyor discussed concerns on 01/08/18 at 1:00 p.m. with the Administrator and Director of Nursing (DON) regarding the omission of an advanced directive and code status for the residents. The DON provided the facility policy for Advance Directives on 1/9/18. The policy originated on 3/2003 and was revised on 11/2017. Procedure, Step 1, indicated that upon the resident's admission to the facility the Sales and Marketing team provides the Advanced Directive to the Social Worker who will place the document in the resident's record. Procedure #4 revealed, The social Work Department provides ongoing education for Residents on the importance of Advance Directives and how to make their health care wishes known in the event that they can no longer participate in health care decisions. This is normally done through quarterly workshops or annual seminars offered in IL .As part of the admission assessment process, Social Work will review with the resident/or legal representative any Advance Directives that may have been provided to the community to confirm they are current and consistent with the resident's wishes. Copies of the most current documents will be filed in the electronic medical record. Social Work will complete a clinical note in the electronic medical record to document such review and any additional education and assistance provided. NJAC 8:39-4.1(a) 2

Based on interview and record review, it was determined that the facility failed to a.) ensure that the Consultant Pharmacist (CP) reported irregularities of drug regimen to the physician, and to b.) act upon the CP report of irregularities found while reviewing the drug regimen. This deficient practice occurred for 2 residents, #12 and #14, of 16 residents reviewed. This deficient practice was evidenced by the following: 1. During the initial tour on 1/3/18 at 10:31 a.m., the surveyor observed Resident #12 in his/her bedroom with a STOP sign and personal protective equipment (PPE) cabinet outside the room. On 1/5/18 at 12:09 p.m., the surveyor reviewed the medical record for Resident #12. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record contained a Universal Transfer Form dated 12/18/17 that noted the resident was transferred to the facility on isolation precautions due [MEDICAL CONDITION]. The surveyor reviewed the December 2017 and January 2018 physician's orders [REDACTED].=40 mEq by mouth (po) one time daily (od), Aspirin 325 milligrams (mg), 1 tab po twice a day (bid), Senna 8.6 mg, 1 tab po as needed (PRN) at bedtime (hs), [MEDICATION NAME] 100 mg, 1 capsule (cap) po PRN at hs, Polyethylene [MEDICATION NAME] 3350 17 gram (gm), 1 packet po PRN at hs. Further review of the medical record failed to reveal that there was a completed PC report in the resident's chart. On 1/9/18 at 9:07 a.m., the surveyor interviewed the Registered Nurse/Clinical Manager (RN/CM). The RN/CM stated that the CP's report was in a separate binder. The surveyor and RN/CM checked the binder for the CP's report and revealed that there was no CP report for Resident #12. The RN/CM stated that she will check with the Director of Nursing (DON) and will get back to the surveyor. On the same day at 9:14 a.m., the surveyor interviewed the DON. The DON informed the surveyor that as a standard of practice, the CP reviews the medication regimen of residents once a month and a written report is submitted via email to the DON. The DON stated that it was the DON's and nursing's responsibility to follow up with the CP's recommendations immediately once the written report received. The DON also stated that once the CP's recommendations were acted upon, the report will be placed on the resident's chart. On the same day and time, the surveyor asked for Resident #12's CP report. The DON stated that she will get back to the surveyor. On 1/9/18 at 12: 36 p.m., the surveyor reviewed the Consultant Pharmacist's Medication Regimen Review (MRR) dated 12/21/17 provided by the facility, which revealed that the CP did not address the sequencing of the bowel regimen for the medications Senna, [MEDICATION NAME], and Polyethylene [MEDICATION NAME] that were ordered by the physician. Further review of the 12/21/17 CP's MRR, provided by the facility, revealed the facility did not act upon the CP's recommendations: Potassium 40 mEq exceeds the manufacturers recommendation of only 20 mEq per dose and to review with physician and change to 20 mEq bid, and Aspirin 325 mg bid appears on the record, please confirm the duration of bid therapy. A review of the medical record revealed there was no documentation showing that the CP's MRR was acted upon by the facility. On 1/10/18 at 12:48 p.m., the DON stated that the facility failed to act upon the CP's recommendations in a timely manner and not until the surveyor notified the facility of the concerns. On 1/10/18 at 9:15 a.m., the DON provided a facility policy for MRR with a version date of 6/2012, which indicated, The Licensed pharmacist will fax written recommendations to the continuing care nursing staff for further action and/or review by the provider, and All written recommendations will be maintained in the resident's permanent medical record. 2. During the initial tour on 1/3/18 at 10:04 a.m., the surveyor observed Resident #14 in their room seated in a wheelchair watching television, with the hospice aide at the bedside. The medical record reflected Resident #14 was admitted to the facility on [DATE] with the following medical [DIAGNOSES REDACTED]. The medical record also revealed that the resident was admitted on hospice care on 11/2/17. The surveyor reviewed the December 2017 and January 2018 physician's orders [REDACTED].=5 mg sublingual (SL) as needed (PRN) every 3 hours (hrs) starting 12/19/17 for terminal restlessness, air hunger, breakthrough pain. A review of CP's MRR dated 12/21/17 provided by the facility, revealed that the facility did not act upon the following CP's recommendations: If this resident's PRN [MEDICATION NAME] order is to continue, please separate it into 2 different orders, each for its own indication (i.e., for air hunger and 1 order for severe pain). A review of the medical record revealed that there was no documentation supporting that the CP's MRR was acted upon by the facility. On 1/10/18 at 12:48 p.m., the DON stated that the facility failed to act upon the CP's recommendations in a timely manner until the surveyor notified the facility of the concerns. On 1/10/18 at 9:15 a.m., the DON provided a facility policy for MRR with a version date of 6/2012 which indicated, The Licensed pharmacist will fax written recommendations to the continuing care nursing staff for further action and/or review by the provider, and All written recommendations will be maintained in the resident's permanent medical record. NJAC 8:39-29.3 (a) (1)

Based on observation, interview, and review of the facility policy, it was determined that the facility failed to appropriately date opened multi-use medication vials to ensure that expired medication was removed from active inventory. This deficient practice was evidenced by: 1. On [DATE] at 10 a.m. the surveyor, in the company of the Registered Nurse/Staff Development Coordinator (RN/SDC), reviewed the inventory of medications and treatment products in the Medication Storage Room. Upon review of the refrigerator contents, the surveyor found 2 opened and undated multi-use medication vials of [MEDICATION NAME] Purified Protein Derivative (PPD) 5 TU (toxic unit)/0.1 ml (milliliter) (Par Pharmaceuticals). On [DATE] at 10:15 a.m., the surveyor asked the RN/SDC the facility's process for dating medications upon opening. The nurse stated the vials are supposed to be dated when they are opened. The surveyor reviewed the facility policy, Omnicare LTC Facility Pharmacy Services and Procedures Manual policy 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles which required, 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. The facility failed to record the date on which the medication vials were opened in accordance with facility policy. NJAC 8:,[DATE].4