Every finding on record at Cranford Park Care

COMPLAINT #2728237 Based on interviews, review of medical records and other pertinent facility documentation on 5/26/26, it was determined that the facility failed to: a) appropriately reconcile a resident's medication at time of admission and b) administer an antibiotic treatment in a timely manner in accordance with professional standard of practice. This deficient practice was identified for 1 of 2 residents (Resident #6) reviewed for medication reconciliation and was evidenced by the following:Resident #6 was not at the facility at the time of the survey. A closed record review was conducted. A review of Resident #6's admission Record revealed that the resident was admitted with diagnoses that included but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hemiplegia affecting left dominant side, type II diabetes, and convulsions. A review of Resident #6's comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 11/14/25, revealed a Brief Interview of Mental Status (BIMS) of 13 out of 15, which indicated that the resident's cognition was intact. A review of Resident #6's care plan (CP) indicated that Resident #6 had a focus related to the resident receiving, [Intravenous] antibiotic therapy (Vancomycin), due to an infection. The focus included an intervention that revealed that medications were to be administered as ordered. A review of Resident #6's After Visit Summary dated 11/8/25, revealed that the resident was to start taking Vancomycin 1.25 gram/250 mL in sodium chloride 0.9% daily on 11/9/25. A review of Resident #6's Medication Administration Record (MAR) for November 2025 revealed a Vancomycin Intravenous Solution was to be administered daily to treat Sepsis arthritis ordered to start on 11/9/25. A review of the 11/9/25 MAR box revealed that a 9 was entered in the box for that day, by the Licensed Practical Nurse (LPN #1), which indicated that the antibiotic was not administered as ordered. Further review of the MAR showed the medication was first administered on 11/10/25 at 3:12 PM. A review of Resident #6's progress notes (PN) revealed nursing notes as follows:-11/8/25 at 8 PM, nursing note revealed that the resident arrived at the facility and that their medications were reviewed, created by LPN #1.-11/9/25 at 6:35 AM, nursing note revealed that a message was left for the Nurse Practitioner (NP) inquiring if the [Vancomycin] should continue and they were awaiting a call back.-11/9/25 at 2:01 PM, an administration note that indicated that the pharmacy was contacted related to the Vancomycin and that it would arrive in the second delivery.-11/9/25 at 6:07 PM, nursing note created by LPN #1, that revealed that the resident had an order for Vancomycin that was to start on 11/9/25 and that the order had not been entered into the computer. LPN #1 reached out to the nurse practitioner and obtained an order to enter the medication and was told to obtain the medication from the backup. The note further indicated that LPN #1 did not have access to the back-up, and the script was sent to the pharmacy. An interview was conducted on 5/26/26 at 2:09 PM with LPN #1 who confirmed that she was the admitting nurse for Resident #6 on 11/8/25. In the presence of the surveyor, she reviewed the PN from 11/8/25, the medication reconciliation, and Resident #6's MAR. She stated that resident was admitted late in the shift, and that she expected that the next shift staff was responsible for the medication reconciliation. She stated that when she returned the next day, she realized that the Vancomycin was not on the medication list, so she contacted the NP to obtain the order. She further stated that the medication was not in the facility back-up box, and that she sent the script to the pharmacy. Whew the surveyor asked why she wrote in the PN that she reviewed the resident's medications on 11/8/25. LPN #1 stated that she reviewed the medications but that she expected the next shift staff to reconcile them. She further stated that the resident had an infection that was being treated with Vancomycin and that the purpose of the medication was to prevent the infection from worsening, and the resident should have received it on 11/9/25. An interview was conducted on 5/26/26 at 4:25 PM with the Nursing Supervisor (NS) who stated that it was the responsibility of the admitting nurse to reconcile medications and that the NS was to verify that medications were reconciled for each new admission. In the presence of the surveyor, the NS reviewed the above documentation related to Resident #6. The NS stated that he could not recall what happened on that day, but he considered the incident a delay in treatment. He further stated that the resident should have started Vancomycin at the facility on 11/9/25. An interview was conducted on 5/26/26 at 4:43 PM with the Director of Nursing (DON) who reviewed the above documentation for Resident #6 in the presence of the surveyor. She stated that the resident should have started the medication on 11/9/25. She further stated that this medication is normally kept in the back-up box, and it should have been there. N.J.A.C. 8:39-27.1(a)

Complaint #2966196, 2955245Based on interviews, record review, and review of other pertinent facility documents it was determined that the facility failed to a) ensure that care and services for a resident's colostomy was provided and b) resident's behaviors related to care and services of the colostomy were monitored and documented in the medical record. This deficient practice was identified for 1 of 2 closed medical records reviewed (Resident #2) for ostomy care.Resident #2 was no longer at the facility. A closed medical record review was conducted. According to the admission record, Resident #2 was admitted to the facility with diagnoses including but not limited to: encounter for attention to ileostomy (a surgical procedure that reroutes waste out of your body by connecting the lowest part of the small intestine (the ileum) to an opening in your abdominal wall, called a stoma); need for assistance with personal care; long term use of immunosuppressive biologic (medication that reduces the activity of the immune system); dependence on renal dialysis (treatment that removes extra fluid and waste products from the blood when the kidneys are not able to); and heart transplant status. The quarterly Minimum Data Set (MDS) an assessment tool dated 03/12/2026 was reviewed. The MDS revealed that Resident #2 had a Brief Interview for Mental Status Score of 15 out of 15 which indicated that the resident's cognition was intact. Review of the MDS further revealed that Resident #2 had an ostomy (surgical procedure that creates an opening in the body for the discharge of body wastes) and required partial or moderate assistance with ostomy hygiene. Review of the Care Plan (CP) for Resident #2 revealed a Focus with an initiation date of 08/31/2026 revealed Resident #2 had anxiety related to fear of ileostomy leakage and availability of ostomy supplies. Interventions related to this goal included but were not limited to monitoring the resident for signs and symptoms of discomfort, with an initiation date of 10/30/2025; reassurance and clear communication about ostomy supply management, with an initiation date of 02/26/2026; and patient teaching about ileostomy care and bag emptying, with an initiation date of 02/26/2026. Review of the Order Summary Report for Resident #2 revealed the following physician orders (POs):Change ileostomy bag every three days and as needed (PRN). The order start date was 12/17/2025.Change ileostomy bag every three days and PRN on night shift. The order start date was 12/18/2025.Change pouching system every three to five days and immediately if leaking. First, apply Cavilon Advanced (a protectant for damaged or at-risk skin) to peristomal skin (area of skin immediately surrounding an abdominal stoma) and allow to air dry; second, apply Coloplast SenSura Mio Convex light ostomy barrier (skin barrier that adheres around the stoma, protects skin and secures the ostomy pouch); third, apply Coloplast SenSura Mio flex high ostomy output pouch (medical device used to collect stool through an abdominal opening called a stoma); fourth, apply Coloplast Bed Drainage Bag (a separate waste collection container connected to the ostomy bag by a long, flexible drainage tube) one time a day every three days for ostomy care. The order start date was 01/25/2026.Change the dry sterile dressing (DSD) to the small stormy (stoma) area above the ileostomy every three days. Monitor for target behaviors for use of alprazolam every night shift: crying, fidgeting with her ileostomy, inability to sleep, and restlessness. Number of behaviors noted: 0 = NA (not applicable), 1 = 1, 2 = 2, 3 = 3 or more. Nondrug interventions: 0 = NA, 1 = redirection, 2 = support/reassurance 3 = reduced stimulation, 4 = 1:1 with staff, 5 = diversional activities, 6 food/snack. Outcome/Result: 0 = NA, 1 = effective, 2 = ineffective. The order start date was 01/15/2026. Complete monthly psychotropic medication review every 17th day of each month. Go to evaluations, initiate drop down, click and Monthly Psychotropic Medication Review then complete review and summarize resident's behaviors in the past month. Every night shift starting on the 17th and ending on the 17th every month. The order start date was 01/17/2026. Review of the medication administration records (MAR) and treatment administration records (TARs) for January, February, and March 2026 revealed that the orders for ileostomy bag changes and the instructions for Resident #2's ileostomy care did not appear on the MARs or TARs. Review of the progress notes (PNs) for Resident #2 showed behaviors directed toward their ileostomy bag on the following dates: 02/06/2026, 02/17/2026, 02/26/2026 and 03/02/2026. Review of the February and March MARs for Resident #2 revealed that no behaviors, non-drug interventions, or outcomes were documented related to the resident's ileostomy on the aforementioned dates and no evidence of interventions provided by staff to address the behaviors. The OSR and MARs and TARs for Resident #2 were reviewed with the Director of Nursing (DON) during an interview on 05/26/2026 at 3:54 PM. The DON stated that the pouch system changes for Resident #2 should have been documented on the Resident's MARs or TARs. The DON stated that the treatment orders should have been transcribed to the MARs or TARs by the nurse who received the order. The DON further stated that if touching and fidgeting with the ileostomy bag was documented in the progress notes it should have been documented in the behavior monitoring section of the MAR. The facility Physician Medication/Treatment Order Transcription policy, with a revision date of 03/22/2026, was reviewed. Under Policy: the facility policy revealed Registered and Licensed Practical Nurses shall transcribe the physician's orders from the Physician's Order Sheet onto the resident's Medication Administration Record or Treatment Record accurately, efficiently and within a timely basis. NJAC 8:39-27.1 (a)

Based on observation, interview and review of other facility documentation it was determined that the facility failed to maintain the resident environment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was evidenced by the following: On 10/31/25 at 10:30 AM, the surveyor observed the following conditions while touring the building from 9:30 AM to 11:30 AM:The carpet on the stairway leading to the B unit was heavily soiled and ripped.Heavy dust and debris accumulation on the stairwell leading to the B Unit. The corridor leading to the nourishment room of the B-Unit, had a broken exposed pipe with visible debris around.room [ROOM NUMBER] had a leaking air conditioner cover which was yellow stained. A white yellow stained towel was noted on the windowsill next to the air conditioner.The windows in the room were covered with dust. The windows had no window treatments or drapes providing a clear view of the street.An observation of room [ROOM NUMBER] revealed there were no windows treatments in the room. From the room the view was not restricted from the street. The residents resided in the room could not be interviewed. The area of the kitchen where the food was being transported to the dumbwaiter (small freight elevator or lift intended to carry food) was heavily soiled with debris. Cobwebs were noted in the corner. The lift tray was soiled and covered with debris.During an interview with the Food Service Director (FSD) on 10/31/25 at 12:05 PM, he confirmed that the area needed to be cleaned.On 10/31/25 at 1:00 PM, the surveyor interviewed the Maintenance and Housekeeping Director (MD/HK) and inquired regarding environmental rounds and a cleaning schedule. The MD/HK stated that environmental rounds was done monthly, and housekeeping staff were to clean the rooms daily. He further stated that he was not aware of the leaking air conditioner and the missing drapes in the rooms. The MD/HK stated he had not received a work order for the air conditioner unit to be repaired. The MD/HK did not provide the last environmental round minutes upon request.On 10/31/25 at 1:30 PM a kitchen staff member provided a cleaning schedule of the dumbwaiter area which indicated that the area was scheduled to be cleaned weekly. The above findings were reviewed with the Licensed Nursing Home Administrator and the Director of Nursing during the exit conference. No additional information was provided.NJAC 8:39 -31.4 (a) (b)e) (f)

Based on observations, interviews, and policy review, the facility failed to ensure the kitchen ceiling was clean above ready-to-eat foods and staff performed adequate hand hygiene when serving meals. The failures had the potential to increase the prevalence and spread of foodborne illness and infection for all 67 of 69 facility residents who received food prepared in the kitchen. Findings include: Review of the Diet Assigned listing, dated 08/20/25, revealed two residents out of the total 69 facility residents received nutrition by tube and did not eat food prepared in the kitchen. 1. During initial observations of the kitchen on 08/18/25 at 9:40 AM, the ceiling above the tray line area was covered with [NAME] of gray/brown dust, some which hung down in strings that were moving in the airflow. During tray line observation in the kitchen on 08/20/25 beginning at 11:34 AM, the ceiling above the tray line area was covered with [NAME] of dust, some which hung down in strings that were moving in the airflow. The dust was above the clean plates, open trays being prepared, serving line, and a cart containing uncovered cheese. At this time, the Dietary Manager (DM) confirmed the ceiling was dusty, and the dust had potential to contaminate the food. He stated this was a task that needed to be done frequently because it was an old building. The DM stated the dust would be removed today. During tray line observation on 08/21/25 beginning at 11:29 AM, the ceiling above the tray line area was still covered with [NAME] of dust, some of which hung down in strings that were moving in the airflow. At this time, the DM confirmed the dust had not yet been cleaned off the ceiling and still had potential of contaminating the food. 2. During tray line observation in the kitchen on 08/20/25 beginning at 11:34 AM, Dietary [NAME] (DC) 1 was observed wearing one pair of gloves throughout the entire service. He periodically touched surfaces off of the tray line, such as the plate warming cart, the oven knobs and handles, and handles of pans on the stove. While wearing the same gloves, DC1 used his hands to pick up bread to place on each resident's plate. DC1 was observed to touch foods like noodles or green beans on the plate to move them and to pick up a grilled cheese sandwich with the same gloves. During tray line observation on 08/21/25 beginning at 11:29 AM, DC1 was again observed while wearing one pair of gloves to wipe the cutting board with a rag, touch pan handles on the stove and touch his pants. Using the same gloves, DC1 picked up bread with his hands to put on each resident's plate. DC1 moved served food on the plate by touching it. At 11:52 AM, DC1's beard net fell below his chin. DC1 adjusted the beard net with his gloved hands and went on to continue serving. The DM reminded DC1 to wash his hands and apply new gloves after touching his beard net. DC1 washed his hands and donned clean gloves, then adjusted the beard net over his face, then continued to serve meals using the same gloves. At this time, DC1 confirmed in interview that he did not change his gloves after touching potentially contaminated surfaces before touching ready-to-eat foods. DC1 stated he had been trained to change his gloves anytime something potentially contaminated was touched for hygiene. The DM confirmed DC1 was touching ready-to-eat foods with his gloved hands and stated he should be using a new pair of gloves to touch food after touching potentially contaminated surfaces. Review of the policy titled, Bare Hand Contact with Food and Use of Plastic Gloves, dated 2017, revealed, Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged orsoiled, or when interruptions occur in the operation . Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. NJAC 8:39-17.2(g)NJAC 8:39-19.7(d)

Based on observation and interview, the facility failed to ensure garbage was covered in area near the entrance to building A next to the stairs down to the kitchen entrance. This failure had potential to cause avoidable pest infestation that could affect all 69 facility residents. Findings include: During observation outside the stairs to the kitchen entrance on 08/18/25 at 9:40 AM, there were three open bins containing garbage bags and a pervasive trash/bowel movement/rotten food odor. None of the three bins had lids. During observation outside the stairs to the kitchen entrance on 08/20/25 at 11:28 AM, there were three open bins containing trash bags and a pervasive trash/bowel movement/rotten food odor. None of the three bins had lids. At this time, the Dietary Manager (DM) stated one bin was for kitchen trash and the others were for housekeeping waste. The DM confirmed none of the bins were covered. The DM stated the bin for kitchen trash was taken out to the dumpster after each meal or whenever it was full. During observation outside the stairs to the kitchen entrance on 08/21/25 at 11:29 AM, there were three open bins containing garbage bags and a pervasive trash/bowel movement/rotten food odor. None of the three bins had lids. The garbage in the kitchen bin was piled high above the top of the bin. There was a pair of used gloves on the ground next to the bin. During an interview on 08/21/25 at 12:37 PM, the Maintenance Director (MD), who also served as the director of housekeeping, stated the housekeeping trash bin was emptied into the dumpster each day at 7:00 AM, 11:00 AM, 3:00 PM, and 5:00 PM. The MD stated the two other housekeeping bins contained soiled linens to be sent out for laundering and were picked up by the company twice a week. The MD confirmed none of the bins were covered, stating the linen bins were provided by the laundry company and did not have lids. The MD stated the kitchen trash bin had a lid and it should be used to cover the trash. The MD stated all trash should be kept under cover to prevent potential infestation. A policy addressing waste disposal was requested from the Administrator on 08/21/25 at 3:33 PM; however, the Administrator stated the facility did not have a policy. NJAC 8:39-19.7

Based on observations, interviews, and policy review, the facility failed to ensure menus were followed for the five residents (Resident (R) 41, R47, R48, R2, and R79) who received a pureed diet out of a facility census of 69. The failure had the potential to contribute to weight loss, malnutrition, or lack of satisfaction with meals for these residents. Findings include: Review of the Diet Assigned listing, dated 08/20/25 and provided on paper, revealed five residents (R41, R47, R48, R2, and R79) out of the total 69 facility residents received pureed foods. Review of the undated Week 1, Cycle Day 4 menu, provided on paper, revealed the 08/20/25 lunch menu for a pureed diet called for 8 ounces (oz) of pureed goulash (split into 4 oz pureed egg noodles and 4 oz pureed goulash), 4 oz of pureed green beans, and one slice of pureed garlic bread. During observation of lunch tray line in the kitchen on 08/20/25 beginning at 11:34 AM, Dietary [NAME] (DC) 1 served a pureed plate with 3-oz portions of pureed goulash, pasta, bread, and green beans. At this time, interview with DC1 confirmed he used 3-oz portions for the pureed foods, and he was unaware the menu called for 4-oz portions. DC1 stated he would look at the menu or each tray card for the correct portion size to serve. Concurrent interview with the Dietary Manager (DM) revealed DC1 did not serve the correct portion size, and the serving size for pureed diets would be corrected to be 4 oz for each food item. Review of the undated Week 1, Cycle Day 5 menu, provided on paper, revealed the 08/21/25 lunch menu for a pureed diet called for 8 oz of rigatoni with Italian sausage, 1 slice garlic toast, and 4 oz of broccoli. Review of the undated Rigatoni with Italian Sausage recipe, provided on paper, revealed it called for Italian sausage, penne pasta, tomato sauce, tomato juice, and mozzarella and parmesan cheeses to be combined and served together. During observation of the lunch tray line in the kitchen on 08/21/25 beginning at 11:29 AM, DC1 served a pureed plate with a pureed rigatoni and sausage without any tomato sauce that appeared green in color. DC1 topped the pureed mixture with a white cheese sauce. Additionally, DC1 did not serve any pureed bread with the meal. Interview at this time with DC1 revealed he used the white cheese sauce for residents who could not have tomatoes but confirmed the resident receiving the plate could have tomatoes and he did not know why he served cheese sauce with the rigatoni and sausage rather than the tomato sauce called for in the menu. DC1 stated he did not include bread in the pureed rigatoni and sausage mixture. DC1 stated, I normally don't do it [pureed bread]. In a concurrent interview, the DM stated he was unsure why the pureed rigatoni with sausage entree was prepared without sauce and served with white cheese sauce. He stated the recipe should have been followed and residents should have received the same entree as the regular menu. The DM agreed the mixture appeared green but did not know why. Review of the policy titled, Menu Planning, dated 2017, revealed, Regular and therapeutic menus will be written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances . Regular and therapeutic menus will be written by the facility's food and nutrition professional in accordance with the facility's approved diet manual, or purchased from an approved vendor. The registered dietitian nutritionist (RDN) or designee will approve all menus. NJAC 8:39-17.2

Based on observation, interview, medical record review, and policy review, the facility failed to follow standard infection control practices for three of the 18 sample residents (Resident (R) 25, R71, and R3). The facility failed to ensure proper personal protective equipment was available for use, proper PPE disposal was available, that staff donned and doffed PPE appropriately, and that hand hygiene was conducted during wound care. These failures increased the risk of the spread of infections and COVID-19 among staff and residents. Findings include: 1. Review of R25's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R25 was admitted to the facility on [DATE] with diagnoses including Covid 19 positive status. Review of R25's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/25, located under the MDS tab indicated R25 was set up assist for oral hygiene, toileting, dressing, and personal hygiene; supervision for showering/bathing. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R25 was cognitively intact. Review of R25's EMR under the Orders tab indicated an order dated 08/15/25, droplet precautions every day and night shift for 10 days. Review of R25's EMR under the Progress Notes tab revealed a progress note dated 08/14/25, PCR [polymerase chain reaction - a test that detects genetic material from an abnormal cell sample] performed in the hospital during her visit . the result positive for COVID-19. Patient placed in droplet precaution x 10 day in A unit. Review of R25's EMR under the Progress Notes tab indicated a progress note dated 08/20/25 . Resident in a private room, on droplet isolation, precautions maintained . Review of a sign that was posted at eye level on the left side of R25's door to her room indicated, STOP Droplet Precautions Everyone Must: Clean their hands, including before entering and when leaving room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. During an interview attempt with R25 on 08/18/25 at 1:40 PM, the surveyor could not locate any face shields or goggles to put on (don) prior to entering R25's room. Surveyor asked Licensed Practical Nurse (LPN) 1 for a face shield. LPN1 checked a secured closet, requiring an entry code, but could not locate a face shield and stated he would have to go to the basement to get a face shield. LPN1 returned with face shields and re-stocked the drawers outside of R25's room. At 1:55 PM, Surveyor removed personal protective equipment (PPE), prior to exiting R25's room, but there was not a receptable to discard PPE. Surveyor questioned LPN1 about a receptable and he stated he would obtain a receptable (a red bin) and place in R25's room. LPN1 explained that when a resident tested positive for COVID-19 it was a joint effort between nursing and maintenance to put the PPE supplies in place. During an observation on 08/20/25 at 8:45 AM, Certified Nursing Assistant (CNA) 2 was observed entering R25's room carrying bathing products and wearing a mask only. CNA2 was observed to exit R25's room at 9:03 AM carrying a plastic laundry bag and wearing a mask. CNA2 was observed sanitizing her hands after placing laundry in the laundry chute. During an interview on 08/20/25 at 1:50 PM, the Infection Preventionist (IP) confirmed R25 had tested positive for COVID-19 and was on droplet precautions. The IP stated mask, face shield, gown, and gloves were required when entering R25's room. When asked how a resident's room was prepared for droplet precautions, the IP stated she would put up signage (droplet precautions) on the outside of the resident's room, place stocked drawers (gloves, gowns, face shield, masks) on the outside of the resident's room, and garbage receptacles (red bins) in the resident's room. The IP stated when a new diagnosis of COVID-19 was determined and she was on site she placed the necessary PPE items outside of the resident's room and when she was not available, nurses on the floor were responsible to put the precaution signage up, stocked PPE drawers in place and red bins inside of resident's room. The IP stated she expected all staff to follow the droplet precaution guidelines when entering R25's room. The IP said she had provided education to facility staff about transmission-based precautions. During an interview on 08/20/25 at 2:05 PM, CNA2 stated when entering the room of a resident positive for COVID-19 she would don a mask, gown, gloves, and a face shield and would remove all PPE and place in the red bin, prior to exiting the resident's room. CNA2 said she would wash her hands after removing her gloves. CNA2 confirmed she did not follow this process when entering R25's room that morning. CNA2 stated she had received training/education regarding donning PPE and when to utilize PPE since she began working at the facility five months ago. Review of the facility's policy titled, Infection Prevention and Control Manual Transmission-Based Precautions reviewed 01/08/25 indicated, Transmission-Based Precautions Transmission-based precautions (a.k.a. Isolation Precautions) refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections . There are three categories of Transmission-Based Precautions: Contact Precautions, Droplet Precautions, and Airborne Precautions . The Centers for Medicare & Medicaid Services (CMS) have outlined three categories of Transmission-Based Precautions: . Droplet - The use of droplet precautions applies when respiratory droplets contain pathogens which may be spread to another susceptible individual. Respiratory pathogens can enter the body via the nasal mucosa, conjunctivae and less frequently the mouth . Respiratory droplets are generated when an infected person coughs, sneezes, talks . Facemasks should be use upon entry into a resident's room . with respiratory droplet precautions. Based upon pathogen or clinical syndrome . gloves and gown as well as goggles (or a face shield in place of goggles) should be worn . COVID-19 Precautions: . Personal Protective Equipment includes: Gloves, Gown, Eye Protections that covers the front and sides, NIOSH-approved N95 or higher respirator . It is essential both to communicate transmission-based precautions to all healthcare personnel . Pertinent signage(i.e., isolation precaution in place, PPE instructions) . PPE must be available near the entrance to the resident room in order for PPE to be donned prior to entry. Review of the facility's policy titled, Personal Protective Equipment (PPE) dated 01/08/25 indicated, Procedure . 2. The facility will ensure that appropriate PPE is readily accessible and that employees use it . a. This includes a system for stocking and restocking . 4. Personal protective equipment will be discarded for resident's on transmission-based precautions or removed before leaving the work area and placed in a . container . disposal. 2. Review of R71's Profile tab of the EMR revealed she was admitted to the facility on [DATE] and had diagnoses including dementia, aphasia, depression, anxiety, and chronic pain. Review of R71's quarterly MDS with an ARD of 07/31/25, located under the MDS tab of the EMR, revealed she was unable to complete the BIMS and had short- and long-term memory problems and severely impaired cognition. The MDS indicated R71 did not have any current pressure ulcers in error (Cross-reference F641: MDS Accuracy). Review of R71's Care Plan, dated 05/23/25 and located under the Care Plan tab of the EMR, revealed, The resident has a stage 3 pressure ulcer on the sacrum r/t [related] to impaired mobility, incontinent. The approaches included, Enhanced barrier protection for infection prevention. Review of R71's EMR under the Orders tab revealed a physician's order, dated 12/09/24, for Enhanced Barrier Protection for infection prevention. Review of R71's August 2025 Treatment Administration Record (TAR), located under the Orders tab of the EMR, revealed a physician's order, dated 08/01/25, for treatment to the sacral wound every Monday, Wednesday, and Friday. The TAR indicated the treatment was completed as ordered throughout the month. During an observation on 08/20/25 at 10:56 AM in R71's room, CNA3 was at R71's bedside providing a bed bath. She was wearing gloves but not wearing a gown. There was a sign on R71's door that read, Enhanced Barrier Precautions and directed staff to don a gown in addition to gloves for high contact activities. There was a bin of gowns and gloves outside the room door. During an interview on 08/20/25 at 11:07 AM, CNA3 stated she had provided incontinence care and bed bath for R71 and did not wear a gown while providing the care. CNA3 stated R71 did not have any active infections, so no PPE was needed other than gloves. During an interview on 08/21/25 at 2:35 PM, the IP stated staff should be using gowns in addition to gloves when providing incontinence care and bed baths to R71, as she had an open chronic wound. The IP stated staff would be reeducated to implement enhanced barrier precautions (EBPs) with residents who had wounds or indwelling medical devices, regardless of infection status. 3. During R3's wound care observation on 08/21/25 at 9:20 AM a sign posted outside R3's room indicated Enhanced Barrier Precautions were in place. Personal protective equipment was available in a storage drawer outside R3's doorway. LPN1 did not don a personal protective gown prior to providing wound care and the Staffing Coordinator (SC) did not don a personal protective gown and gloves prior to assisting with R3's positioning during the wound care treatment. During R3's wound care observation on 08/21/25 at 9:20 AM, LPN1 removed the dirty dressing from the right upper back pressure ulcer and doffed (removed) the dirty gloves. LPN1 did not sanitize or wash hands prior to donning clean gloves. LPN1 cleaned the wound with betadine, doffed dirty gloves and reapplied clean gloves without sanitizing or hand washing. LPN1 then applied a foam dressing to the right upper back pressure ulcer. During an interview on 08/21/25 at 9:35 AM, LPN1 stated that he should have put on a personal protective gown. LPN1 stated that he had been trained to implement EBP. LPN1 stated that he had not been trained to use hand sanitizer or wash hands between each glove change. During an interview on 08/21/25 at 9:50 AM, the SC stated that she forgot to put on a gown prior to assisting with R3's positioning during the treatment and she knew she was supposed to. During an interview on 08/21/25 at 1:55 PM, the IP stated that she had already begun training on handwashing, glove changes, EBP, and transmission-based precautions. The IP stated that she would follow up with random audits to ensure the training is adhered to. Review of the policy titled, Infection Prevention and Control Manual: Transmission-Based Precautions, dated 01/08/25, revealed, Enhanced Barrier Precautions: expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multidrug-resistant organisms] to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Review of the facility policy titled Enhanced Barrier Precautions Policy reviewed on 01/08/25 provided by the facility indicated Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with [infection or colonization with an MDRO]. The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDROs to employee's hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids. High contact resident care activities include dressing, bathing/showering/ transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use, and wound care. Review of the facility policy titled Glove Technique (Non-Sterile) reviewed on 01/08/25 indicated that It is the policy of this facility to don (put on) clean non-sterile gloves in accordance with Standard and Transmission-based Precautions, (i.e., when anticipating touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and non-intact skin or when a resident in Transmission-Based Precautions). Gloves cannot be worn for the care of more than one resident. Perform hand hygiene after the removal of gloves. NJAC 8:39-19.4

Based on interview, medical record review and policy review, the facility failed to allow one of one resident (Resident (R) 33) reviewed for care planning in a sample of 18 residents the right to participate in the development and implementation of her person-centered plan of care. This failure increased the risk that the resident would not have any direct input into her plan of care.Findings include: Review of R33's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R33 was admitted to the facility on [DATE] with the diagnoses of dementia, depression, and type II diabetes. Review of R33's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/25, located under the RAI [Resident Assessment Instrument] tab indicated R33 needed set up assist for eating; supervision for oral hygiene; partial/moderate assist for bed mobility and toileting; showering/bathing, dressing and personal hygiene were substantial /maximum assist. The MDS showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R33 was cognitively intact. Review of R33's EMR under the Progress Notes tab indicated there was no documentation regarding R33 being invited by the Social Service Director (SSD) or any staff member to attend her care plan meetings. Review of R33's EMR under the Care Plan tab indicated there were care plan meetings held for R33 on 10/15/24 (admission), 01/14/25 (quarterly) and 04/16/25 (quarterly). Upon review of the documentation associated with each care plan meeting there was no documentation regarding R33 being invited to or attending the care plan meeting. During an interview on 08/19/25 at 9:20 AM, R33 and her family member (F33) both denied ever being invited or taking part in a care plan meeting since R33's admission to the facility. During an interview on 08/21/25 at 8:45 AM, the SSD stated R33 had been invited to her care plan meetings. SSD stated that once the care plan meeting was scheduled but prior to a resident's care plan meeting she hand delivered an invitation form to all residents or called the responsible party if the resident was confused. The SSD explained she did not document this process in the resident's medical record or retain a copy of the invitation. The SSD confirmed the resident invite was not documented in the care plan meeting notes. Review of the facility's policy titled, Interdisciplinary Care Plan revised 03/21/25 indicated, The interdisciplinary team includes: The physician, nursing, the resident and or concerned party . social services.Procedure: . 11. Each meeting will allow ample time to address the needs of the resident. Suggested time allotted for the review is 15 minutes . 15. Resident and family will be invited to their prospective meeting and allotted time for input . II. The Care Plan: . 4. Responsible Discipline Column . b. If resident or family attend IDCP (Interdisciplinary Care Plan) conference and agree with the care goals, add their initials in responsible discipline column. Review of the facility's policy titled, Resident Rights revised 03/07/25 indicated, Policy It is the policy of the facility that employees and staff will treat all residents with kindness, dignity and respect the rights of each residents as outlined in the federal nursing home reform law. Procedure . 4. Each resident is educated about their rights upon admission, information about . rights to participate in ones own care. NJAC 8:39-4.1(a)3NJAC 8:39-11.2(e)

Based on observations, record reviews, and interviews, the facility failed to provide the residents and/or their representatives with written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for two of 18 sample residents (Resident (R) 11 and R17) reviewed for Advanced Directives. This failure created the potential for the residents' wishes not to be followed if the residents were unable to speak for themselves. Findings include: 1. Review of R11's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed R11 was admitted to the facility on [DATE]. Review of R11's EMR revealed no documentation that R11 had an Advance Directive or that the facility provided written information to the resident, or the resident representative concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Review of R17's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed R17 was admitted to the facility on [DATE]. Review of R17's EMR revealed no documentation that R17 had an Advance Directive or that the facility provided written information to the resident, or the resident representative concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 08/20/25 at 10:30 AM, the Social Services Director (SSD) stated, I ask the resident or the resident representative if they have an Advance Directive, and I talk to the resident and the resident representative on admission about an Advance Directive, but we use the POLST [Physician Order for Life Sustaining Treatment] form. When asked if information was provided on how to formulate an Advance Directive she stated, No, I only give them the POLST form in order to make their choices and then make a note in their chart in the progress notes. During an interview on 08/20/25 at 3:30 PM, the administrator stated, We use the POLST form, but during admission the SSD does discuss Advance Directives with the residents and resident representatives. We will do whatever we need to correct this. NJAC 8:39-4.1(a)2,4NJAC 8:39-9.6

Based on record review, interviews, and policy review, the facility failed to ensure written notice to the resident or representative of the transfer to the hospital included a statement of the appeal rights, information on how to file an appeal, and appeals contact information for two of two residents (Resident (R) 73 and R2) reviewed for hospitalization in a sample of 18 residents. This failure created the potential for a lack of understanding of appeal rights should the resident not be permitted to return or disagree with the reason for transfer, potentially causing confusion or distress upon transfer. Findings include: 1. Review of R73's Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with a diagnosis of discitis (infection of the spine). He was discharged from the facility on 05/20/25. Review of R73's Discharge - Return Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/25, located under the MDS tab of the EMR, revealed he was transferred to a hospital.Review of R73's Acute Transfer Form, dated 05/20/25, located under the Miscellaneous tab of the EMR, revealed it included a reason for transfer, transfer location, and Ombudsman contact information. There was no statement of the resident's appeal rights, information on how to file an appeal, or contact information for the appeal agency. During an interview on 08/21/25 at 8:55 AM, the Social Services Director (SSD) stated she was responsible for completing the transfer form and providing to the resident or representative. The SSD stated she was not aware appeal rights and information were required to be included in the notice for transfers to the hospital. During an interview on 08/21/25 at 10:08 AM, the Administrator stated he did not believe appeal rights and information were necessary to include in the hospital transfer form, as residents were not sent to the hospital against their will. He stated he understood it was a regulatory requirement to include the appeals information. 2. Review of R2's Face Sheet located under the Profile tab of the EMR revealed R2 was admitted to the facility on [DATE] with diagnoses including malnutrition, heart disease, type II diabetes, and cardiac pacemaker. Review of R2's five-day MDS with an ARD of 07/10/25, located under the EMR MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating R2 was severely cognitively impaired Review of the facility provided form for R2 titled, New Jersey Universal Transfer Form indicated R2 was transferred to the hospital on [DATE] due to a hemoglobin (a protein in red blood cells that carries oxygen and carbon dioxide) of 6.8 gm/dL (grams per deciliter) (normal level for a male is between 13.5 - 18 grams). Review of the facility provided untitled and undated form regarding the notice of transfer and bed hold policy, indicated on 05/26/25 a transfer notice was completed for R2. This form provided only the NJ Long-Term Care Ombudsman contact information in the event R2 or his family disagree with the transfer. There was no statement of the resident's appeal rights, information on how to file an appeal, or contact information for the appeal agency included on the form. Review of R2's EMR under the Progress Notes tab indicated a progress notes dated 05/26/25, 2 pm . Hemoglobin 6.8 NP [Nurse Practitioner] aware of labs and order to send out to . hospital. NP called out to residents' son and hospital to make aware of transfer . During an interview on 08/21/25 at 8:45 AM, the SSD stated she was not aware that the notice of a resident's transfer needed to include information about a resident's right to appeal the transfer/discharge and the agency a resident can contact regarding the appeals process. During an interview on 08/21/25 at 10:02 AM, the Administrator stated he was not aware that the notice of a resident's transfer needed to include information about a resident's right to appeal the transfer/discharge and the agency a resident can contact regarding the appeals process. Review of the Transportation - Acute Emergency policy, dated 03/22/25, revealed, A 'Transfer Form' will be completed and sent with the resident upon discharge from the facility. The policy failed to address the required contents of the form. NJAC 8:39-4.1(a)31,32

Based on interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the presence of a stage III pressure ulcer for one of three residents (Resident (R) 71) reviewed for pressure ulcers out of a sample of 18. This failure created potential for an incomplete or ineffective plan of care related to pressure ulcer treatment and healing measures. Findings include: Review of R71's Diagnosis tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and had diagnoses including dementia, aphasia, depression, anxiety, and chronic pain. Review of R71's quarterly MDS with an Assessment Reference Date (ARD) of 07/31/25, located under the MDS tab of the EMR, revealed she did not have any current pressure ulcers. Review of R71's Care Plan, dated 05/23/25 and located under the Care Plan tab of the EMR, revealed, The resident has a stage 3 pressure ulcer on the sacrum r/t [related] to impaired mobility, incontinent. The approaches included, Apply Heel Booties to B/L [both] feet q [every] shift . Enhanced barrier protection for infection prevention. Review of R71's Report of Consultation, dated 06/20/25 and provided by the facility on paper, revealed the resident's healed sacral wound had re-opened at a stage III and outlined a treatment order and offloading instructions. Review of subsequent wound care consultation reports, dated 07/18/25 and 08/01/25, revealed the continued presence of a stage III sacral pressure ulcer and continued treatment orders. Review of R71's Treatment Administration Record (TAR), dated July 2025 and located under the Orders tab of the EMR, revealed a physician's order, dated 06/23/25, for wound treatment: Sacral Wound: Cleanse with saline. Apply Collagen powder Mon, Wed, Fri and cover with dressing. Zinc oxide to periwound. Protective Dressing. Reposition side to side. Monitor for changes one time a day every Mon, Wed, Fri. The TAR indicated these treatments were provided as ordered. This order was changed on 07/30/25 to, Sacral Wound: Cleanse with saline. Apply prisma/collagen and cover with foam border gauze every Mon, Wed, Fri. Zinc oxide to periwound. Protective Dressing. Reposition side to side. Monitor for changes every night shift every Mon, Wed, Fri. The TAR indicated this treatment was completed on 07/30/25. During an interview on 08/21/25 at 1:30 PM, the MDS Coordinator (MDSC) stated she missed coding R71's sacral pressure ulcer, as there was no documentation in the EMR to indicate the pressure ulcer had re-opened after healing on 06/11/25. The MDSC stated the paperwork showed R71 had a pressure ulcer during the lookback period for the MDS and should have been coded. The MDSC stated she would make this correction immediately. Review of the Resident Assessment MDS Policy, dated 03/20/25, revealed, It is the policy of the facility to ensure that each resident who is admitted receives the care needed to meet his or her individual needs. An assessment shall be completed by a registered nurse, initially upon admission or readmission. And, in conjunction with the interdisciplinary team in accordance with regulatory mandates, a comprehensive assessment utilizing the Minimum Data Set (MDS) shall be completed according to the required time frames. NJAC 8:39-33.2(d)

Based on interview, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 71) reviewed for pressure ulcers out of a sample of 18 received physician-ordered pressure ulcer prevention measures. This failure created potential for development of avoidable pressure ulcers and associated risks for pain, infection, and slow healing.Findings include: Review of R71's Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and had diagnoses including dementia, aphasia, depression, anxiety, and chronic pain. Review of R71's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/25, located under the MDS tab of the EMR, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and had short- and long-term memory problems and severely impaired cognition. R71 was dependent on staff for all activities of daily living and bed mobility. R71 was at risk for pressure ulcer development and used a pressure-reducing device for her bed. The MDS indicated R71 did not have any current pressure ulcers in error (Cross-reference F641: MDS Accuracy). Review of R71's Care Plan, dated 05/23/25 and located under the Care Plan tab of the EMR, revealed, The resident has a stage 3 pressure ulcer on the sacrum r/t [related] to impaired mobility, incontinent. The approaches included, Apply Heel Booties to B/L [both] feet q [every] shift . Enhanced barrier protection for infection prevention. Review of R71's EMR under the Orders tab revealed a physician's order, dated 07/28/24, for Bilateral Booties to feet q [every] shift dated 08/15/24, to Apply Cushion Pad between left foot toes and offload with heel boots one time a day for wound care. Review of R71's Nursing - Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 07/29/25 and located under the Notes tab of the EMR, revealed R71 was at high risk for pressure ulcer development. During an observation on 08/19/25 at 9:19 AM, R71 was lying in bed in her room. R71 had a pressure-reducing mattress on the bed and had wedges in place for positioning. Her legs were bent at a 90-degree angle and laying to the side. No boots were visible under the covers. During an interview and concurrent observation in R71's room on 08/20/25 at 8:06 AM, R71 was lying in bed with thick socks on. Licensed Practical Nurse (LPN) 1 stated R71 did not have any pressure ulcers on her feet. LPN1 uncovered R71's feet and confirmed she did not have boots on. LPN1 removed R71's socks and confirmed there was no cushion pad on her left toes. During interviews and concurrent observations in R71's room on 08/20/25 10:32 AM, 11:07 AM, and 12:54 PM, R71 was lying in bed with thick socks on. Certified Nursing Assistant (CNA) 3 confirmed R71 was not wearing boots while lying in bed. R71's socks were not removed at these times. During an interview and concurrent observation in R71's room on 08/20/25 at 3:16 PM, R71 was lying in bed with thick socks on. CNA1 confirmed R71 was not wearing boots. CNA1 stated R71 did not have boots and did not use them. R71's socks were not removed at this time. During an interview and concurrent observation in R71's room on 08/21/25 at 10:26 AM, R71 was lying in bed with socks on. LPN1 confirmed she did not have heel boots on, but stated her thicker socks worn on 08/20/25 were considered booties. LPN1 removed R71's socks and confirmed there was no cushion/pad on her left toes. During a subsequent interview on 08/21/25 at 10:36 AM, LPN1 stated he had not been applying the heel boots or cushion pad to her left toes as she no longer had any skin issues on her foot. LPN1 stated he did not have a good answer why the orders were initialed as completed each shift on the TAR. LPN1 stated the orders should be discontinued as they were no longer needed. During an interview on 08/21/25 at 2:16 PM, the Director of Nursing (DON) stated booties and heel boots were large foam boots used to offload pressure from the heels, and both terms meant the same thing. The DON stated the thick socks worn by R71 were not considered booties or heel boots. The DON stated the use of heel boots and a cushion pad for the left toes were current orders and still should be implemented daily in order to prevent recurrence of pressure ulcers on the feet, especially since R71 was at high risk for pressure ulcer development due her limited mobility. Review of the Wounds: Pressure Ulcers & [and] Ulcers of Different Types Protocol for: Prevention, Assessment & Monitoring, Intervention, Documentation, and Evaluation, dated 03/21/25, revealed, Interventions for prevention of residents who are classified as either high, moderate, or low risk for developing a pressure ulcer are individualized to that resident's need and are listed on the resident's plan of care. It is important to note, in the development of the plan of care, the resident's choice is valued in consideration of interventions. The interventions are monitored by direct care staff and are evaluated individually daily. NJAC 8:39-27.1(e)

COMPLAINT #NJ00179350, NJ00182926 Based on interviews, medical record review, and review of other pertinent facility documents on 6/3/25, 6/5/25, and 6/19/25 it was determined that the facility failed to consistently document in the Documentation Survey Report on care provided to dependent residents according to facility policy and protocol for 3 of 3 residents (Resident #1, Resident #5, and Resident #6) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted with diagnoses that included but were not limited to: Dementia, Muscle weakness, Diabetes Mellitus Type 2 The surveyor reviewed Resident #1's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/10/25, which indicated that Resident #1 had a BIMS of 9 out of 15, indicating moderate cognitive impairment. The MDS further indicated that the resident required assistance with Activities of Daily Living (ADLs). A review of Resident # 1's Documentation Survey Report v2 (DSR) dated May 2025, for completion of ADL under Intervention / Task did not indicate that Personal Hygiene was documented at the following times: ADL- Personal Hygiene: During the 7:00AM to 3:00PM shift, the following days did not have documentation: 5/3/25, 5/4/25, 5/7/25, 5/9/25, 5/10/25, 5/11/25, 5/12/25, 5/13/25, 5/14/25, 5/17/25, 5/18/25, 5/24/25, 5/25/25, 5/30/25. During the 3:00PM to 11:00PM shift, the following days did not have documentation. 5/2/25, 5/5/25, 5/6/25, 5/9/25, 5/10/25, 5/11/25, 5/16/25, 5/17/25, 5/19/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/24/25, 5/25/25, 5/30/25, 5/31/25. During the 11:00PM to 7:00AM shift, the following days did not have documentation: 5/2/25, 5/3/25, 5/4/25, 5/9/25, 5/10/25, 5/15/25, 5/16/25, 5/17/25, 5/22/25, 5/23/25, 5/24/25, 5/30/25, 5/31/25. 2. According to the AR, Resident #5 was admitted with diagnoses including but not limited to Seizures, Muscle weakness and difficulty walking. A review of the quarterly MDS, an assessment tool dated 5/21/25, revealed that Resident #5 had a BIMS score of 9 out of 15, indicating that Resident #5 had moderate cognitive impairment. The MDS further indicated that the resident required assistance with ADLs. A review of Resident # 5's DSR, dated May 2025, for completion of ADL under Intervention / Task did not indicate Personal Hygiene was documented at the following times: ADL- Personal Hygiene: During the 7:00AM to 3:00PM shift, the following days did not have documentation 5/3/25, 5/4/25, 5/7/25, 5/9/25, 5/10/25, 5/11/25, 5/14/25, 5/16/25, 5/18/25, 5/20/25, 5/24/25, 5/25/25, 5/30/25, 5/31/25. During the 3:00PM to 11:00PM shift, the following days did not have documentation. 5/2/25, 5/3/25, 5/5/25, 5/9/25, 5/10/25, 5/11/25, 5/16/25, 5/17/25, 5/18/25, 5/19/25, 5/22/25, 5/24/25, 5/25/25, 5/30/25, 3/31/25. During the 11:00PM to 7:00AM shift, the following days did not have documentation. 5/2/25, 5/3/25, 5/9/25, 5/10/25, 5/15/25, 5/16/25, 5/22/25, 5/23/25, 5/24/25, 5/25/25, 5/30/25 3. According to the AR, Resident #6 was admitted with diagnoses including but not limited to Alzheimer's Disease, Dementia, Muscle Weakness, Diabetes Mellitus and Encounter for Palliative Care. A review of the resident's annual MDS, an assessment tool used to facilitate the management of care, dated 01/18/2025, revealed that Resident #6 had a BIMS score of 3 out of 15, which indicated the resident had severe cognitive impairment. The MDS further indicated that the resident required assistance with ADLs. A review of Resident # 6's DSR, dated January 2025, for completion of ADL under Intervention / Task did not indicate that, Personal Hygiene, and Toilet Use were documented at the following times: ADL- Personal Hygiene: During the 7:00AM to 3:00PM shift, the following days did not have documentation 1/1/25, 1/2/25, 1/3/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/22/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25 During the 3:00PM to 11:00PM shift, the following days did not have documentation. 1/2/25, 1/3/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, 1/16/25, 1/17/25, 1/20/25, 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25. During the 11:00PM to 7:00AM shift, the following days did not have documentation. 1/1/25, 1/2/25, 1/3/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/15/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25. ADL-Toilet Use: During the 7:00AM to 3:00PM shift, the following days did not have documentation. 1/1/25, 1/2/25, 1/3/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/22/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25. During the 3:00PM to 11:00PM shift, the following days did not have documentation. 1/2/25, 1/3/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, 1/16/25, 1/17/25, 1/20/25, 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25. During the 11:00PM to 7:00AM shift, the following days did not have documentation. 1/1/25, 1/2/25, 1/3/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25. During an interview with the surveyor on 6/5/25, at 11:21AM, the Certified Nursing Assistant (CNA) stated, that all care provided to the resident was documented in the [electronic medical record]. She further stated, Documentation is important to know what type of care was provided to the resident. It effects their condition. In the presence of the surveyor the CNA reviewed the DSR for Resident #6, and stated that there should not be blanks on the form, All [boxes] should be filled in. During an interview with the surveyor on 6/5/25 at 12:12 P.M. The Licensed Practical Nurse (LPN) stated that CNAs were responsible for providing and documenting ADL care. He stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were responsible to follow up and ensure that ADL documentation was completed. He further stated that if a CNA was not documenting, he would report that to the DON. During an interview with the DON on 6/3/25, at 4:44 P.M., he stated that CNAs were responsible for documenting in the electronic record. He further stated that there, Should not be any blanks in the [electronic medical record]. Review of facility's Charting and Documentation policy, revised on 2/15/25, revealed in the policy statement that, Proper documentation and charting will be maintained on each resident . It further revealed under section 7 of the Documentation in [Electronic Medical Record] that, All skilled and unskilled services must be documented . Review of the facility's Activities of Daily Living policy, revised on 3/7/25, revealed that, The purpose of this procedure is to assist the nurse in gathering information about the overall condition of the resident and his or her performance of activity of daily living. It further revealed under the Documentation of Care Provided that the Certified Nursing Assistants (CNAs) document all the care they provided to the residents assigned to them during their shift in [the electronic medical record]. NJAC: 8:39-27.1(a); 35.2(d)6

Complaint #NJ 00182926 Based on interviews, medical records reviews, and review of other pertinent facility documentation, on 06/03/25, 06/05/25, and 06/19/25, it was determined that the facility failed to revise a care plan after an annual assessment for a cognitively impaired resident that needed assistance with meals. The facility also failed to follow its Care Plan policy. This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for care plans and was evidenced by the following: Resident #6 was not at the facility at the time of the survey. A closed record review was conducted. According to the admission Record (AR), Resident #6 was admitted to the facility with diagnoses which included but were not limited Alzheimer's Disease, Dementia, Muscle Weakness, Diabetes Mellitus and Encounter for Palliative Care. A review of the resident's annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/18/2025, revealed that Resident #6 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicated that the resident had severe cognitive impairment. The MDS further indicated that Resident #6 required Substantial/ Maximum assistance with eating. A review of Resident # 6's Care Plan (CP) did not reveal the level of assistance the resident required when eating. A review of Resident #6 Progress Notes (PN) revealed a nursing note dated 01/12/25, at 10:56 P.M, that revealed that the resident, Requires complete total care with [Activities of Daily Living] at all times. Review of the IDCP (Interdisciplinary Care Planning)/Care Conference Note, dated 01/23/25 at 11:36 A.M., revealed that the Director of Nursing (DON), documented that the resident was a Max assist x1 with ADL . During an interview on 06/05/25 at 2:17 P.M, the DON stated that he and the Assistant Director of Nursing (ADON), were responsible for updating care plans. He stated that the CP was important because it showed that the needs of the resident were being addressed. He further stated, The MDS and the care plan should reflect the same information. In the presence of the surveyor, the DON reviewed Section GG of Resident #6's MDS and stated that the resident was a max assist related to eating. The DON also reviewed the IDCP/Care Conference note, and stated that, Max assist x1 with ADLs includes eating. He also reviewed Resident #6's CP and stated that the CP should have reflected the max assist for eating, and that he should have updated it. Review of the facility Care Plan policy, revised 2/21/25, revealed that, .all residents admitted to the facility will have comprehensive person-centered care plans that provide for their needs . The CP policy further revealed under section 10 that, Care plans will be updated in a timely manner and necessary revisions made when there are changes in conditions. NJAC: 8:39-11.1; 11.2(i); 27.1(a)

Based on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for the PBJ Report submission for Fiscal Year (FY) Quarter 1 2024 (October 1-December 31) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area indicating the facility failed to submit data for the first Fiscal Year Quarter to CMS. The dates of the first quarter included October 1, 2023, through December 31, 2023. On 3/19/24 at 10:00 AM, the Licensed Home Administrator (LNHA) informed the survey team that the facility used a third party to submit the PBJ Staffing Data Report to CMS. The third party did not provide a CMS validation or any proof of submission to CMS for staffing reported for the FY Quarter 1 2024. On 3/27/24 at 11:15 AM, the surveyor interviewed the LNHA, in the presence of another surveyor, regarding communication of staffing with CMS and he stated, We submitted everything with this third party, and they communicate with CMS. I don't have any documentation or proof on hand to reflect that CMS received the data for the FY Quarter 1 2024. The survey team explained the concern to the LNHA that CMS did not have the data. The LNHA was not able to provide additional proof of documentation indicating the third party communicated to CMS. On 3/27/24 at 12:00 PM, the surveyor requested the policy and procedure from the LNHA for PBJ submission/communication to CMS. The facility's policy and procedure were received from the LNHA on 3/27/24 at 12:30 PM, the policy titled PBJ Reporting, with the revised date of 2/8/24 did not indicate the timeframe of submitting data to CMS and who was responsible for submission. NJAC 8:39-41.3(a)

Based on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 7 of 19 residents (Resident #41, 9, 53, 3, 50, 66, and #10) and reviewed for resident assessment. According to the Long-Term Care RAI 3.0 User's Manual Version 1.18.11, updated October 2023, the MDS is a comprehensive tool and a federally mandated process for clinical assessment of all residents. It must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. This deficient practice was evidenced by the following: On 3/19/24, at 9:30 AM, the surveyor reviewed the facility task that includes residents' MDS assessments, which was triggered under the survey facility task as MDS record over 120 days old. 1. Resident #41 was observed to have a Quarterly MDS (QMDS) with an Assessment Reference Date (ARD) on 1/30/24, which was due to be transmitted to CMS no later than 2/13/24. However, the QMDS was not submitted to CMS until 3/6/24. 2. Resident #9 was observed to have a QMDS with an ARD on 2/1/24, which was due to be transmitted to CMS no later than 2/15/24. However, the QMDS was not submitted to CMS until 3/6/24. A review of QMDS with an ARD on 11/1/23 was due to be transmitted to CMS by 11/15/23. The QMDS was not submitted to CMS until 12/5/23. 3. Resident #53 was observed to have Annual MDS (AMDS) with an ARD on 1/28/24, which was due to be transmitted to CMS no later than 1/11/24. However, the AMDS was not submitted to CMS until 3/6/24. A review of QMDS with an ARD on 10/30/23 was due to be transmitted to CMS by 11/14/23. The QMDS was not submitted to CMS until 12/5/23. 4. Resident #3 was observed to have AMDS with an ARD on 1/26/24, which was due to be transmitted to CMS no later than 1/13/24. However, the AMDS was not submitted to CMS until 3/6/24. 5. Resident #50 was observed to have QMDS with an ARD on 1/25/24, which was due to be transmitted to CMS no later than 1/12/24. However, the QMDS was not submitted to CMS until 3/6/24. 6. Resident #66 was observed to have QMDS with an ARD on 1/26/24, which was due to be transmitted to CMS no later than 1/13/24. However, the QMDS was not submitted to CMS until 3/6/24. 7. Resident #10 was observed to have AMDS with an ARD on 1/28/24, which was due to be transmitted to CMS no later than 1/11/24. However, the AMDS was not submitted to CMS until 3/6/24. A review of QMDS with an ARD on 10/30/23 was due to be transmitted to CMS by 11/14/23. The QMDS was not submitted to CMS until 12/5/23. A review of the MDSC's undated Final Validation Report for Residents #41, 9, 53, 3, 50, 66, and #10 revealed that The submission date is more than 14 days after Z0500B on this new assessment. On 3/25/24 at 11:46 AM, the survey team met with the MDSC. The MDSC informed the surveyors that the facility has no specific policy regarding MDS and follows the RAI Manual. The MDSC stated that submissions were late because the discipline needed to complete their assessment. On 3/25/24 at 12:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Infection Preventionist Nurse (IPN), and Clinical Nurse Consultant (CNC). The surveyor notified the facility management of the above findings and concerns. On 3/26/24 at 02:15 PM, the survey team met with the CNC, LNHA, DON, IPN, and MDSC. The facility management did not respond to the above findings and concerns. NJAC 8:39 - 11.1

Based on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 5 of 19 residents reviewed (Resident # 69, # 9, # 57, #63, and # 24). The deficient practice was evidenced by the following: 1. The surveyor reviewed Resident # 69's records. The resident was discharged from the facility and according to the Discharge Return Anticipated MDS, an assessment tool used to facilitate the management of care, dated 2/23/24, the resident was assessed as being discharged to the hospital. A review of Resident # 69's progress notes dated 2/23/24 revealed the resident had actually been discharged home, against medical advice. On 3/25/24 at 11:49 AM, the surveyor interviewed the MDS Coordinator (MDSC), who stated that the MDS under section A, which is she completes, for Resident #69 should have indicated discharge to home and that it was an error that it indicated discharge to the hospital. During an interview on 3/25/24 at 12:15 PM, the surveyor brought the above concerns to the attention of the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA). 46889 2. On 03/20/24 at 11:40 AM, the surveyor observed Resident #9 in bed lying comfortably alert, oriented with confusion, and able to answer the surveyor's inquiry. The surveyor reviewed Resident #9's hybrid (combination of paper and electronic) medical record as follows: A review of the Admission Record (an admission summary) (AR) documented that Resident #9 was admitted to the facility with diagnoses that included but were not limited to essential hypertension (high blood pressure). The resident's most recent Quarterly MDS (QMDS) assessment, dated 2/1/24, reflected that Resident #9 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderate cognition impairment. Section O Special Treatments, Procedures, and Programs revealed that Resident #9, the pneumococcal vaccination (which helps protect against serious illnesses like pneumonia and meningitis), was up to date. There is no record that a pneumococcal vaccine was given to Resident #9. The immunization record shows that the resident's son refused the pneumococcal vaccination on 6/1/23. A review of QMDS dated [DATE], section D Resident Mood Interview (PHQ-9), signed by the social worker on 2/6/24, revealed no record of a PHQ-9 assessment interview done on the ARD of 2/1/24. A review of QMDS dated [DATE], section E Behavioral Symptoms, signed by the social worker on 2/6/24, revealed no Behavioral Symptoms assessment interview on the ARD of 2/1/24. On 3/25/24 at 11:46 AM, the survey team met with the MDSC. The MDSC stated that the pneumococcal vaccination should reflect the accurate status of the resident's vaccination history and that the resident had refused the vaccine. 3. On 03/21/24 at 10:47 AM, the surveyor observed Resident #57 sitting in bed, alert and oriented, able to answer the surveyor's inquiry. The surveyor reviewed Resident #57's hybrid medical record as follows: A review of the AR documented that Resident #57 was admitted to the facility with diagnoses that included but were not limited to leukemia (a cancer of the blood). The resident's most recent Admission MDS (AMDS) assessment, dated 12/21/23, reflected that Resident #57 had a BIMS score of 15 out of 15, indicating intact cognition. A review of AMDS dated [DATE], section D PHQ-9, signed by the social worker on 12/23/23, revealed no record of a PHQ-9 assessment interview done on the ARD of 12/21/23. A review of AMDS dated [DATE], section E Behavioral Symptoms, signed by the social worker on 12/27/23, revealed no Behavioral Symptoms assessment interview on the ARD of 12/21/23. On 03/26/24 at 11:11 AM, the surveyor interviewed the Registered Nurse (RN) who worked in the facility for [AGE] years as a charge nurse and works closely with the MDSC. The RN stated that she tried as much as possible to check the MDS assessment before submitting it. She checked and reviewed the look-back period. The surveyor asked the RN where to find the assessment, such as PHQ-9 and Behavioral assessment. The RN showed the surveyor the Evaluations tab in the electronic medical record but could not find PHQ-9 and Behavioral interview assessment for Resident #9 QMDS dated [DATE] and Res. #57 AMDS dated [DATE], respectively. On 03/27/24 at 9:50 AM, the surveyor interviewed the MDSC and stated that the social worker completed MDS assessment sections C, D, E, and Q and that the interview should be conducted on the ARD date, 12/21/23. 39885 4. On 3/20/24 at 12:22 PM, the surveyor observed Resident #63 seated in a wheelchair in the dayroom eating lunch. The surveyor reviewed Resident #63's electronic medical record. A review of Resident #63 AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anemia (condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), muscle weakness (decreased strength in the muscles) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident #63's quarterly MDS, an assessment tool used to facilitate the management of care, dated 02/15/24, reflected that the resident had a BIMS score of 03 out of 15, which indicated that Resident #63's cognition was severely impaired. Further review of Section O Special Treatments, Procedures, and Programs indicated that under O0300 Resident #63's pneumococcal vaccine was up to date. A review of Resident #63's electronic medical record under the Immunization tab included the following: Pneumovax Dose 1 (pneumococcal vaccine) Immunization Req. It did not indicate a date that it was given as complete or a date with historical to indicate that the resident had the vaccination in the past. On 3/21/24 at 01:50 PM, in the presence of the survey team, the surveyor requested the LNHA and DON provide information on Resident #63's vaccinations. On 3/25/24 at 11:25 AM, the DON provided the surveyor a document that included the following: Immunization Resident #63- .PNA Vaccine the consent was signed by the daughter, not given. On 3/25/24 at 11:47 AM, in the presence of the survey team, the surveyor interviewed the MDSC regarding the process for MDS. The MDSC stated that she inputted the data and that a Registered Nurse would review the information to make sure it was accurate before the MDSC submitted the MDS. The surveyor asked the MDSC where the vaccination status was located that she entered into the MDS. The MDSC stated that she looked in the electronic medical record under the immunization section. She then stated that if the information was not in the electronic medical record that she would ask the resident or the resident representative. The surveyor then asked the MDSC what req meant on on Resident #63's immunization section. The MDSC stated that it meant request. The surveyor then asked the MDSC the reason Resident #63's MDS was coded up to date for the pneumococcal vaccine when the resident did not receive the vaccination. The MDSC stated that she would have to look into it. On 3/25/24 at 12:31 PM, in the presence of the survey team, the surveyor told the LNHA, DON, Infection Preventionist and Clinical Nurse Consultant the concern that Resident #63 was not offered the pneumococcal vaccination prior to surveyor inquiry and that the MDS was coded inaccurately to indicate that Resident #63's pneumococcal vaccination was up to date when the resident had not received the vaccination. On 3/26/24 at 9:47 AM, in the presence of the survey team and LNHA, the DON stated that the MDSC was in-serviced and that she corrected Resident #63's MDS. A review of the printed MDS that the facility provided indicated that the printed view was different from the electronic view. On 3/26/24 at 11:04 AM, the surveyor showed the MDSC the different codes in the viewable and printed version of the MDS. The MDSC confirmed that the viewable version in the electronic medical record was a 1 and that indicated a yes for up to date and that the printed version indicated a 1 and that indicated a no for up to date. The MDS Coordinator stated that the correct answer that she inputted was a yes for up to date. On 3/26/24 at 02:16 PM, in the presence of the survey team, the surveyor told the LNHA, DON, IP and Clinical Nurse Consultant the concern that the MDS printout was different then the transmitted version in the electronic medical record. On 3/27/24 at 9:13 AM, the LNHA provided an email from the company for the electronic medical record. The email dated 3/26/23 included the following: We believe we have identified a defect affect Section O0300A printing as No on the print version of the MDS, and it is currently under review. We will notify you of any updates via email as they become available. Currently, there is no workaround for this problem. However, it is important to note that while the response from the MDS assessment is appearing correctly. The facility did not provide any additional information. 38327 5. On 3/21/24 at 11:03 AM, the surveyor observed Resident #24 in the dining area (also known as the activity room) laying in the geri chair (or geriatric chair, which is a large padded chair with wheeled bases and is designed to assist seniors with limited mobility) with eyes closed and the body covered with a blanket. The surveyor reviewed the hybrid medical records of Resident #24 as follows: According to the AR, Resident #10 was admitted to the facility with a diagnosis that included but was not limited to essential hypertension (abnormally high blood pressure that's not the result of a medical condition), unspecified osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain), unspecified glaucoma (a group of eye conditions that can cause blindness), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) without complications, and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident's comprehensive MDS (cMDS) with an ARD of 12/13/23 revealed in Section C Cognitive Status with BIMS score of 3 out of 15 which reflected that the resident's cognition was severely impaired. Section O Special Treatments, Procedures, and Programs revealed that Resident #24 was offered and declined the pneumococcal vaccination (which helps protect against serious illnesses like pneumonia and meningitis). The immunization record in the electronic medical record (eMR) revealed that Resident #24 had the pneumococcal vaccine on 6/02/23. The above pneumococcal vaccine was signed as administered in the June 2023 electronic Medication Administration Record (eMAR). On 3/25/24 at 11:46 AM, the survey team met with the MDSC. The MDSC informed the surveyors that the facility had no specific policy regarding MDS, the facility follows the RAI Manual. The MDSC stated that the pneumococcal vaccination on 12/13/23 should reflect the accurate status of the resident's vaccination history that the resident had received the pneumococcal vaccine. On 3/25/24 at 12:27 PM, the survey team met with the LNHA, DON, Infection Preventionist Nurse (IPN), and Clinical Nurse Consultant (CNC). The surveyor notified the facility management of the above findings and concerns. On 3/26/24 at 02:15 PM, the survey team met with the CNC, LNHA, DON, IPN, and MDSC. The facility management did not respond to the above findings and concerns. NJAC 8:39-11.2(e)1

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to implement an intervention timely that was recommended by the wound physician. This deficient practice was identified for one of one resident (Resident #28) reviewed. This deficient practice was evidenced by the following: On 3/18/24 at 11:02 AM, the surveyor observed the Resident #28 lying in bed on an air mattress. The resident responded to questions in a faint voice. The resident gave permission to speak with the spouse who was in the room. The spouse stated, [The resident] came here because of a stroke about six months ago. On 3/18/24 at 11:26 AM, the surveyor interviewed the daughter who stated, [the resident] was in the hospital in New York for gastrointestinal bleed and has renal cancer that metastasized to the brain. The resident also had another brain bleed and had radiation therapy recently in the hospital. [the resident] has a sacral wound, stage four, from the hospital from a year ago. On 3/20/24 at 11:25 AM, observed the resident lying in bed, on an air mattress. The resident stated, I am fine for now, I have no complaints. On 3/20/24 at 11:28 AM, interviewed License Practical Nurse (LPN) #1 from Unit A, who worked in the facility for seven years. The LPN stated, The resident gets out of bed (OOB) M-W-F between 1-4 PM with Hoyer (mechanical lift) transfer. The resident gets therapy. The sacral wound has not declined, it's stable. On 3/21/24 at 12:49 PM, observed the resident lying in bed. The resident stated, I ate good today and I feel fine. The resident's daughter who was in the room stated, They mentioned yesterday that the wound team will look into a wound VAC (vacuum assisted closure, to remove excess exudate and promote healing). The nursing supervisor spoke to me on Monday and mentioned at this point that they are keeping the wound sterile for possible application of a wound VAC. I spoke to the wound doctor's office on Monday, and they said there's no indication of infection and would determine soon for possible wound VAC. I am waiting to hear back when that would be applied. On 3/21/24 at 12:57 PM, interviewed LPN #1, who stated, The sacral treatment order is cleaning and packing with Dakin's solution, doctor [name redacted] and his assistant did wound rounds yesterday. The wound is improving, and the treatment orders are the same. I haven't got any orders yet about the wound VAC. On 3/21/24 at 1:02 PM, interviewed Registered Nurse (RN), Director of Nursing (DON), who stated, The resident is being followed by a wound care team. The wound report comes to me every week and I review it. If there's a new treatment, I am updating the orders for anything new. I haven't seen anything yet for an order of a wound vac. A record review of the Admission Record in the Electronic Health Record (EHR) reflected the Resident #28 was admitted to the facility with medical diagnoses which included but not limited to: dysphagia following nontraumatic intracerebral hemorrhage (difficulty swallowing due to bleeding in the brain); protein calorie malnutrition; diabetes mellitus type II with hyperglycemia and chronic kidney disease; gastrostomy tube(feeding tube); dysarthria (difficulty speaking); kidney cancer; secondary lung, and bone cancer; and anemia (low red blood cells). According to the Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 1/15/24 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe impaired cognition. The assessment further reflected that the resident had a Stage four sacral wound on admission, tube feeding and on a mechanically altered diet and required maximal to total assistance with Activities of Daily Living (ADLs). The resident's care plan initiated on 1/8/24 indicated Resident #28 had a sacral pressure ulcer on admission related to immobility. A review of the Order Summary in the resident's EHR reflected Multivitamin & Mineral Oral Liquid (Multiple Vitamins w/ Minerals) Give 15 ml by mouth one time a day for Supplements, ordered on 3/19/24; Zinc Sulfate Oral Tablet 220 (50 Zn) MG (Zinc Sulfate) Give 1 capsule via G-Tube two times a day for Wound Healing for 14 Days, ordered 3/18/24; Sacral Wound cleanse with wound Dakin's, pack with Daikin's Soaked Kerlix, and foam dressing daily. Zinc Oxide to peri wound, reposition side to side, monitor for changes. every night shift for Wound Healing-Start Date 03/14/2024. A review of the wound consult team notes dated on 1/10/24 reflected sacral wound Stage 4 measuring 2.5x2x1.5cm, 30% slough (dead cells), 60% granulation (new tissue) and 10% muscle; Wound consult notes on 2/14/24 reflected measurements of 2x1.5x2cm, 10% slough, 90% granulation, undermining (extending to the muscle) at 1 o'clock and recommendation for wound VAC protocol; Wound consult notes on 2/21/24 reflected recommendations for wound VAC protocol; Wound notes on 3/13/24 recommended wound VAC for sacral wound; Wound consult notes on 3/20/24 reflected measurements of 3x2x1.8cm, 90% granulation, 10% bone, undermining at 12 o'clock and recommend wound VAC; Updated wound consult notes on 3/20/24 after surveyor inquiry reflected treatment orders clean and pack with Dakin's solution until wound VAC is available. Wound consult notes from 2/14/24 through 3/20/24 (total of four weeks), indicated recommendations for wound VAC for sacral wound with no evidence from the facility of an order or treatment clarification. A review of the 1/8/2024 3:41 PM LPN #2 documented on the Braden Scale for Predicting Pressure Ulcer Risk Evaluation note in the EHR reflected Braden Score of 13 indicating moderate risk for skin impairment. A Braden score of 10 on 3/22/24 indicating high risk for skin impairment. A review of the RN Health Status Note Text on 3/22/24 at 4:20 PM: Resident lying in bed awake, alert, verbally responsive to simple questions, denied pain or discomfort, no moaning or facial grimacing noted, respiration easy and regular, no distress. Resident's spouse and daughter visiting. Informed resident, spouse, and daughter that I am going to do wound care to sacral wound and apply wound VAC, procedure explained, questions answered, resident, spouse and daughter agreed. Resident positioned on left side, old dressing removed, moderate amount of sero-sanguineous drainage noted, sacral wound cleaned with NS, wound VAC applied at 125 mm/Hg continuous suction, tolerated procedure well, repositioned for comfort, off load wound, no distress. I informed resident's spouse and daughter that state surveyors would like to observe wound care on Monday, and I asked them for their consent, resident's spouse and daughter declined. A review of the RN Health Status Note Text on 3/22/24 at 5:51 PM: I offered resident's spouse and daughter that I can call MD to order pain medication prior to wound care, resident's spouse and daughter declined, they want to continue PRN (as needed) pain management. Will continue to monitor. On 3/25/24 at 9:15 AM, the surveyor interviewed the DON regarding what was the plan of the wound team from February 14, 2024, to current recommendations for wound VAC protocol written on the wound report, the DON stated, It was written on the bottom of the report and the wound doctor never communicated to me about his plan for the wound VAC and there was no order. On 3/25/24 at 10:45 AM, the surveyor observed the resident sleeping on the bed with air mattress and a wound VAC applied to sacral wound. The resident's daughter and spouse were in the room and the daughter stated, The wound VAC application was to start the wound healing, it's now at the point where it's the next step and it was applied last Friday. On 3/25/24 at 10:55 AM, the surveyor interviewed LPN #2, who has been working at the facility for five years stated, The wound VAC was started last Friday, and I didn't hear anything about the wound VAC prior to last Friday. On 3/25/24 at 11:14 AM, the surveyor called the wound doctor [name redacted] regarding recommendation of wound VAC protocol from 2/14/24 and call went into voicemail. On 3/25/24 at 12:02 PM, the surveyor requested permission from the daughter and spouse regarding sacral wound observation and the family refused. On 3/25/24 at 12:15 PM, the surveyor interviewed the assistant medical director, [name redacted] from the wound consultation group, with the survey team present, the doctor stated, I am the one who reviews the wound reports weekly, but I have not seen the resident. The wound VAC was on back order in February 2024. Our doctor should have documented it on the wound report. We should have documented better and done a separate treatment because Dakin's solution can actually impair wound healing if wound has granulation tissue, there's a better wound treatment. The facility did not provide any documentation of the wound VAC being on back order or that the recommendation for wound VAC was clarified by the facility. On 3/26/24 at 9:46 AM, the surveyor met with the License Home Administrator (LNHA) and the DON in the presence of the survey team and discussed the concern regarding the delay in application of the wound VAC from 2/14/24 through 3/20/24. The surveyor interviewed the DON regarding the wound note on 2/14/24 pertaining to the wound VAC, the DON stated, I should have questioned and followed up with the doctor to clarify what he meant by wound VAC protocol. On 3/26/24 at 10:49 AM, the surveyor interviewed the wound doctor, [name redacted] in the presence of the survey team. The doctor stated, The standard wound VAC needs to be applied for Wound VAC protocol. I believe the resident went to the hospital and came back. The wound has no infection, minimal slough, it's improving. It's the facility's protocol to acquire the VAC but that sometimes takes a couple of days. It's not jeopardizing their treatment until they get the VAC. Continue the same treatment until the VAC comes was the plan. I spoke to my scribe about documentation, and he told me he put that note in the report. Dakin's is the appropriate treatment while waiting for a VAC. We can work on the notes better, I agree with you that it should have been communicated to the facility and documented initially that a VAC was recommended and should have been implemented once the VAC was available. A review of the facility policy and procedure titled Wound Care: Decubitus/Pressure Ulcers with revision date of 2/8/24 revealed, Each resident will have preventative measures instituted to prevent the development of or further deterioration of skin integrity. The wound doctor will recommend treatment based on his assessment during wound rounds. NJAC 8.39-25.2(c); 27.1(e)

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to ensure a.) implementation of interventions designed by the occupational therapist to stimulate functional performance, and prevent further decline, and b.) the interdisciplinary team provided timely revision to the care plan (CP). This deficient practice was identified for one (1) of one (1) resident reviewed for limited range of motion, Resident #29 and was evidenced by the following: 1. On 3/25/24 at 10:33 AM, the surveyor observed the resident with one foot out of the blanket, the chest, and both hands were covered with a blanket. On 3/26/24 at 9:24 AM, the surveyor and the Certified Nursing Assistant (CNA) assigned to the resident, entered the resident's room. The resting hand splint (RHS; a medical device, functional hand brace, wrist, and finger immobilizer) was observed next to the resident's bedside table. The CNA stated that she had fed the resident, who at that time threw the RHS on to the floor. At that time, the CNA described the resident as dependent, required total care, was contracted, and had a splint for the hand which the resident often refused. At 9:30 AM, the surveyor and the CNA reviewed the electronic communication record (eCR; brand redacted) together. The eCR was the system the CNA's used to document tasks associated with activities of daily living (ADL), via touch screen. The eCR did not reflect a task associated with a splint. At that time, the CNA stated that the documentation of the donning and doffing of the splint was not assigned to her. The CNA stated that she reported to the medication nurse on duty who then documented on the electronic Medical Record (eMR) the donning, doffing and refusals of the medical device [splint]. The surveyor reviewed the hybrid medical record for Resident #29. A review of Resident #29's Admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included unspecified convulsions, cerebellar stroke syndrome (a stroke that can cause problems with movement, vision, speaking, thinking and behavior), and unspecified dementia (memory problems). A review of Resident #29's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 03/05/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that Resident #29's cognition was severely impaired. Further review of section O. 0500 Restorative Nursing Program, under section C for splint or brace assistance was marked, zero. This number indicated the number of days the restorative program was performed, in the last 7 calendar days, for the resident. According to the Occupational Therapy (OT) and Plan of Treatment (PT) dated 12/2/23, the resident was seen for the quarterly assessment. The assessment indicated that the resident presented with left sided weakness, spasticity (stiff or rigid muscle) of the shoulder, elbow and hand and lower left extremity. The patient required total assistance of all aspects of ADL, to mobilize out of bed onto the geri chair (an adaptive chair) and for feeding tasks. The resident received services one to three times per week. A review of the OT Discharge Summary dated 1/8/24, revealed that on 1/2/24, the resident was discharged from receiving rehabilitative services. The discharge recommendations included. -safely wear a resting hand splint on left hand, up to 8 hours - an elbow extension splint (a medical device to relieve contracture for those with paralysis or significant unbalanced muscle strength on the left elbow, up to 8 hours -will improve ability to safely, and efficiently perform eating tasks with partial/moderate assistance . A review of the Order Summary Report (OSR), the list of active physician orders (PO) as of 3/25/24, included an order for left wrist extension splint (LWES; a medical device that prevents unwanted flexion and extension of the wrist while allowing movement of the fingers and thumb) - On during day shift. Off during night shift. Check skin integrity every shift, every day, and night shift, started on 10/8/22. Further review of the OSR did not reflect a physician order for the following: - resting hand splint (RHS), left hand - elbow extension splint (EES), left elbow On 3/26/24 at 11:07 AM, during an interview with the surveyor, the Certified Occupational Therapy Assistant (COTA)/Director of Rehabilitation (DOR) stated she had no access to the eMR and the eCR. She was unable to view what was donned or doffed by the nursing staff and/or refused by the resident. At that time, the COTA/DOR stated, We don't check the eMR, and that it was the responsibility of the Director of Nursing (DON) to monitor nursing tasks. At 11:41 AM, the surveyor and the COTA/DOR entered the resident's room and confirmed the RHS was in the room and that the elbow splint was not in the room. At 11:44 AM, the surveyor and the COTA/DOR entered the C-wing dining/day room. The surveyor observed the resident seated in a geri chair, reclined, and a hand roll within the left palm. The COTA/DOR assessed the resident and confirmed the resident had a hand roll within the left palm, however the resident was not wearing a left EES, left hand RHS and LWES. At 11:58 AM, the COTA/DOR stated that the evaluating therapist was part-time and was not in the building at that time. She would reach out to let him know about the missing orders. At that time, the surveyor, and the Licensed Practical Nurse (LPN) reviewed the electronic Treatment Administration Record together for the PO of the LWES - On during day shift. Off during night shift. Check skin integrity every shift, every day, and night shift, started on 10/8/22. The order reflected a check mark for the day shift. At that time, the LPN acknowledged that the order for the LWES and skin check should have been separated, for clarity of tracking. The LPN also confirmed the resident was not wearing the LWES and had a hand roll without an order. A review of the succeeding quarter, OT and PT evaluation dated 3/11/23, under current referral included that Nursing staff had been educated on the continuance of the need to don splints to prevent further contracture . Nursing is managing patient's contracture impairment. 2. A review of the quarterly Interdisciplinary Care Plan (IDCP) Care Conference Note of the last two quarters dated 12/7/23, and 3/15/24 under section 10. Restraint/Devices/Side Rail Review did not reflect any documentation relating to medical devices from nursing. The record also did not show a tab where rehabilitative services were able to enter information. On 3/26/24 at 11:07 AM, during an interview with the surveyor, the COTA/DOR stated as part of her responsibilities, she participated in the quarterly IDCP team meetings. At that time, the COTA/DOR informed the surveyor that once a resident was discharged with medical device recommendations, the CNAs were educated by the evaluating therapist. Followed by an evaluation of the CNA's competency of donning and doffing a splint or positioning a wedge or cushion. We then put it on the CP because we want it to carry over. A review of the Treatment Administration Record (TAR) for January 2024, February 2024, and March 2024, did not reflect refusals of the application of the LWES and did not include the tracking of the donning, doffing of the following: - resting hand splint (RHS), left hand - elbow extension splint (EES), left elbow A review of the resident's Care Plan (CP) included a focus that indicated the resident was at risk for left hand contracture dated/revised on 6/12/23; the interventions reflected that the resident would demonstrate increased range of motion of the left hand to increase functional bed mobility and self-care tasks dated/revised on 6/12/23. Further review of the CP goals included that the resident would wear the left resting hand splint during the PM (nighttime) hours to prevent contracture and increase joint mobility dated/revised on 3/1/24. The CP did not include the LWES, the EES and the hand roll. On 3/26/24 at 2:16 PM, in the presence of the survey team the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Infection Preventionist (IP), the Nursing Consultant and MDS Coordinator (MDSC), the surveyor discussed the concern regarding the failure to develop and implement the OT's recommendations of promoting functional stabilization and preventing contracture from 1/2/24, including the IDCP team's quarter review of 3/15/24. The concern regarding the failure to ensure revision of the individualized CP was also discussed. On 3/27/24 at 9:33 AM, during a follow- up interview with the surveyor, the COTA/DOR stated she attended the quarterly IDCP team meetings but did not document on the conference note. She instead verbally communicated with the IDCP team and emailed the rehabilitation team of the plan for the resident. At that time, the surveyor asked the COTA/DOR why the omissions of the medical device recommendations were not acted upon on 1/2/24 and at the quarterly meeting on 3/15/24. At that time, the COTA/DOR stated that nursing had not verbalize that the medical devices were missing, and the order for the LWES from 10/8/22, was incorrect. She acknowledged the OT recommendations should have been acted upon at the time of the recommendation on 1/2/24, and the errors including omissions, should have been captured for correction at the quarterly meeting on 3/15/24. At that time, the COTA/DOR stated the communication between nursing and rehabilitation services could be better. We started a QAPI (Quality Assurance and Performance Improvement, a data driven and proactive approach to quality improvement) yesterday. No further information was provided. A review of the facility provided policy, Restorative Program, Resident: Ambulation Function Maintenance dated 3/22/24, included the following under Procedure. 1. The therapy Department, in collaboration with Nursing initiates the Functional Maintenance Program for Ambulation. The program goal is set in collaboration with Therapy, Nursing, and the individual resident. 2. As per specific recommendation from therapy .The specific recommendation shall be documented on the resident's plan of care. A review of the facility provided policy, Care Plan, Rehabilitation Services dated 2/8/24, included Procedure under section 9. Care Plans will be updated in a timely manner and necessary revision made when there are changes in condition. NJAC 8:39-11.2 (e)(1)(2), 27.1(a)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to a) follow through with the Dietitian's recommendation for one (1) of two (2) residents (Resident #24), b) ensure the Interdisciplinary team (IDT) was aware of the resident's significant weight loss according to the standard of clinical practice for one (1) of two (2) residents (Resident #24), and c) ensure that the re-weigh was done according to the standard of clinical practice and facility policy for two (2) of two (2) residents, Resident #24 and #57, reviewed for nutrition. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 3/21/24 at 11:03 AM, the surveyor observed Resident #24 in the dining area (also known as the activity room) laying in the geri chair (or geriatric chair, which is a large padded chair with wheeled bases and is designed to assist seniors with limited mobility) with eyes closed and the body covered with a blanket. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #24. According to the Admission Record (admission summary), Resident #10 was admitted to the facility with a diagnosis that included but was not limited to essential hypertension (abnormally high blood pressure that's not the result of a medical condition), unspecified osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain), unspecified glaucoma (a group of eye conditions that can cause blindness), type 2 diabetes mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy) without complications, and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident's comprehensive Minimum Data Set (cMDS), and assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 12/13/23 revealed in Section C Cognitive Status Brief Interview for Mental Status (BIMS) score of 3 out of 15 which reflected that the resident's cognition was severely impaired. The cMDS Section K Swallowing/Nutritional Status revealed that the resident had a weight loss of 5% or more in the last month or a loss of 10% in the last six months. The personalized care plan showed a focus on Nutrition that was initiated on 12/15/20 and revised on 3/21/24 with interventions that included but were not limited to monitor my weights and lab (laboratory) as avail (available) initiated on 12/15/20. A review of the Weight Summary revealed that on 12/08/23 the resident's weight was 121.5 pounds (lbs) with warning notes that included the following: -5.0% change [comparison weight 11/10/23, 132.0 lbs, -8%, -10.5% lbs] -7.5% change [comparison weight 11/10/23, 132.0 lbs, -8%, -10.5% lbs] A review of the IDCP (Interdisciplinary)/Care Conference Note with an effective date of 12/21/23 included Nutritional Status that was electronically signed by the Dietitian on 01/05/24 that the resident was triggered for a significant weight loss x 1 (one) month (8%) and the Dietitian recommended for albumin (test measures the amount of the protein albumin in the blood) level. The Clinical Dashboard in the electronic medical record (eMR) for a facility bulletin board showed that on 12/21/23, the Dietitian created documentation for the resident's recommendation for an albumin level. A review of the Order Summary Report (OSR) for December 2023, January 2024 through March 21, 2024, showed that there was no order for an albumin level. The Results tab in the eMR showed that the last lab done was on 10/04/23. The 12/21/23 Nutrition/Dietary Note in the Progress Notes (PN) showed that Resident #24 was triggered for a significant weight loss x 1 month (8%). The PN did not include that the reweigh was planned, attempted, and refused by the resident. Further review of the PN revealed that there was no documentation from the Physician, Nurse Practitioner, and Nurses about the 12/21/23 notes of the Dietitian about the significant weight loss and the albumin level that was recommended. In addition, the PN did not include documentation that the resident was offered and declined the reweigh and albumin level check. On 3/21/24 at 11:14 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) in the presence of two surveyors. The LPN informed the surveyor that Resident #24 was cognitively impaired, at times required assistance from staff with eating, appetite varied, and most of the time appetite was good. The LPN stated that the resident was on Glucerna shake and the resident takes it well. On that same date and time, the LPN stated that she was not aware of the resident's significant weight loss. She further stated that she was not sure if the weight meeting existed at the facility. At that same time, the surveyor asked the LPN what was the facility's process and standard of practice with regard to weight loss. The LPN informed the surveyor that the Dietitian would notify the nurse verbally of the weight loss and recommendations. The LPN stated that she can also see the Dietitian's recommendations in the Clinical Dashboard in the eMR for weight loss. She further stated it was the nurse's responsibility to call the physician for the recommendation to obtain an order which included an order for lab if that was the recommendation of the Dietitian. The LPN also stated that if the doctor declined the recommendation it was an expectation that the nurse would document it in the PN. At this time, the surveyor asked the LPN why the 12/21/23 recommendation of the Dietitian for an albumin level in the Clinical Dashboard that the LPN showed was not followed. The surveyor also asked why there was no documentation that the physician was called about the recommendation. The LPN responded, I do not know what happened. On 3/21/24 at 11:45 AM, the surveyor interviewed the Registered Dietitian (RD, also known as the Dietitian). The RD informed the surveyor that the facility's process regarding weight loss generally, the RD enters the weight in the eMR specifically in the weight section, and if there was a five (5) pounds plus or minus weight discrepancy, a reweigh will be done. The RD stated that she also verified and assessed the resident on what happened and why there was significant weight change or weight loss. She further stated that the Nurse Practitioner (NP) of the resident's primary physician will be notified via a [name of an app] (a messaging app that uses the internet to send messages, images, audio, or video) of a list of residents with weight changes that included significant weight loss. On that same date and time, the RD informed the surveyor that there was an IDCP weight meeting where the RD, Director of Nursing (DON), and MDS Coordinator (MDSC) participated, and discussed weight loss. The RD stated that there was no specific date when the IDT met and there was no documentation of the meeting. The RD further stated that the nurses would call the doctor and put the orders that included the recommendations for blood work and supplements as applicable. The surveyor then asked the RD if she followed up on her recommendations and if it was documented. The RD responded Yes, I follow up, but I do not document if the recommendations were not followed through, because the RD did not want other people to be blamed. At that same time, the surveyor notified the RD of the above findings and concerns. The RD stated that she knew Resident #24 and that the resident started to trend down with weight. The RD further stated that she liberalized the resident's diet today, and increased the fortified food. The surveyor asked the RD why her recommendation on 12/13/23 to check for albumin level for significant weight loss was not followed, and the RD did not respond. On 3/21/24 at 01:49 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The surveyor notified the facility management of the above concerns and findings regarding weight loss. On 3/25/24 at 10:19 AM, the surveyor interviewed the NP. The NP informed the surveyor that she was not notified of the resident's significant weight loss and the recommendation to check the albumin level. The NP stated that usually when the RD recommended, the NP and physician approved and they (NP and physician) documented it in the eMR. The NP acknowledged that if it was not documented in the eMR about the significant weight loss, it meant that she was not aware. At that same time, the NP stated that she was not aware of the facility's policy to reweigh the resident if there was a significant weight loss. The surveyor notified the NP of the above findings and concerns. On 3/25/24 at 10:34 AM, the surveyor interviewed the DON in the presence of the NP. The DON stated that it was an expectation if a resident had a weight loss, the RD would evaluate the resident and provide recommendations, and nursing and physician would be notified. The RD will notify the DON of the significant weight loss and recommendations as well. The DON informed the surveyor that he was not aware of the significant weight loss of Resident #24 that was documented by the RD on 12/21/23 and 02/22/24. At that same time, the DON stated that the last weight meeting was held late last year, and unable to remember the date because it was informal and not documented. He further stated that he did not remember that in the last weight meeting in December 2023, the resident's significant weight loss was discussed, which was why he was not aware of the resident's weight loss problem. 46889 2. On 3/21/24 at 10:47 AM, the surveyor observed Resident #57 sitting in bed, alert and oriented, able to answer the surveyor's inquiry. The surveyor reviewed Resident #57's hybrid medical record as follows: A review of the AR documented that Resident #57 was admitted to the facility with diagnoses that included but were not limited to leukemia (a cancer of the blood). The resident's most recent Admission MDS (AMDS) assessment, dated 12/21/23, reflected that Resident #57 had a BIMS score of 15 out of 15, indicating intact cognition. The AMDS Section K Swallowing/Nutritional Status revealed that the resident had a weight of 175 pounds. A review of the Care plan showed a focus on Nutrition, initiated on 12/19/23 and revised on 3/20/24, with interventions that included but were not limited to, monitoring weights and reporting any significant changes to the IDCP team. A review of the Weight Summary revealed the following: On 2/2/24 at 12:55, 165.8 Lbs. (pounds) On 2/1/24 at 16:57, 175.0 Lbs. The 2/20/24 Nutrition/Dietary Note in the PN showed that Resident #57 was triggered for a significant weight loss x 1 month (5.5%). The PN did not include that the reweigh was planned, attempted, and refused by the resident. On 3/26/24 at 10:33 AM, the surveyor, in the presence of the team, interviewed the dietitian over the phone. She stated that the resident should have been weighed when the discrepancy was noted. The dietitian confirmed that there was no re-weigh after 2/2/24 with nine (9) pounds lost. She added that she would tell Nursing to re-weigh the resident. She stated that she informed the NP regarding the weight loss. On 3/27/24 at 11:23 AM, the surveyor interviewed the NP, who has been working in the facility for a year. She stated that the dietitian or nursing did not inform her of the resident's weight loss; if she does, she will order lab work and re-weigh the resident. A review of the facility's Weighing the Resident Policy with a revision date of 3/21/24 that was provided by the RD included that the weights of residents are taken on admission and monitored monthly. If clinically indicated, weights are monitored more often as needed or as the physician orders. The purpose is to record the actual weight of residents and to keep accurate records of weight gain or loss. Included in the procedure: chart weight on the appropriate form in the chart, any increase or decrease of more than five pounds should be called to the Charge Nurse's attention and reweigh. Document weight and notify the dietician as needed. On 3/26/24 at 02:15 PM, the survey team met with the Clinical Nurse Consultant, LNHA, DON, Infection Preventionist Nurse, and the MDS Coordinator (MDSC). The facility management did not respond to the above findings and concerns. NJAC 8:39-11.2(d)(e)(1)(f), 17.1(c), 17.2(d), 27.1(a)

Based on observation, interview, record review, and review of other pertinent facility documents on 6/7/2022, it was determined that the facility failed to maintain water temperatures at a safe level to prevent potential [CONDITION(S)] or injury. This deficient practice was identified in 3 of 3 units (A unit (includes A floor, Upper Annex and Lower Annex), B unit and C unit) reviewed for water temperatures. The facility's failure to monitor and follow up on water temperatures after adjusting the boiler setting, placed Resident # 23, as well as all other residents, at risk for unsafe water temperatures to prevent potential [CONDITION(S)] or injury, which resulted in an Immediate Jeopardy (IJ) situation that began on 6/5/22. The IJ ran from 6/5/22 to 6/8/22, including the first date that the Maintenance Director (MD) increased the water temperature without monitoring or following up on the temperatures. The facility's Licensed Nursing Home Administrator (LNHA) was notified of the IJ on 6/7/22 at 5:00 PM. An acceptable written Removal Plan was received on 6/8/22 at 5:07 PM. The Removal Plan was verified by the survey team onsite on 6/8/22 at 10:59 AM, lifting the immediacy, and the survey team continued verification of the Removal Plan onsite throughout the survey while onsite for the dates of 6/6/22, 6/7/22, 6/8/22, 6/9/22, 6/10/22, 6/13/22, 6/14/22, 6/15/22 and 6/16/22. The evidence was as follows: Reference: State Operations Manual, Effective November 28,2017 Sub-Reference: [NAME], A.R. Herriques, F.C. Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burn. Am J Pathol 1957; 23;695-720; Understanding Potential Water Heater Scald Hazards. A White Paper Developed by the American Society of Sanitary Engineering Scald Awareness Task Group,Published: March 2012(R) A burn is damage to the skin and underlying tissue caused by heat, chemicals or electricity. [CONDITION(S)] damage or destroy the skin cells. Scalds result from the destruction of one or more layers of the skin due to contact with hot liquids or steam. The temperature to which the skin is exposed and the length of time the skin is exposed to the burning substance determine the depth of injury. Table 1. Time and Temperature Relationship to Serious [CONDITION(S)] Water Temp Time Required for a 3rd Degree Burn to Occur 155 F 68 C 1 sec 148 F 64 C 2 sec 140 F 60 C 5 sec 133 F 56 C 15 sec 127 F 52 C 1 min 124 F 52 C 3 min 120 F 48 C 5 min 100 F 37 C Safe Temperatures for Bathing (see Note) NOTE: [CONDITION(S)] can occur even at water temperatures below those identified in- the table, depending on an individual ' s condition and the length of exposure. On 6/7/22, during a Recertification Standard Survey, the survey team noted that the water temperature in bathroom sink located in the lobby was hot to the touch. The surveyor calibrated the thermometer at 11:45 AM. At 12:28 PM, the surveyor went into the two rooms that are located on the first-floor lobby area. In Unit C room 12 the sink hot water temperature was 124.5 degrees Fahrenheit (degrees F) and the sink hot water temperature in Unit C room 13 was 146.5 degrees F. At 12:32 PM, the surveyor interviewed Resident # 23, who stated that a Certified Nursing Assistant (CNA) gave the resident a shower this morning and the water was too hot. The resident stated that he/she asked the CNA to adjust the temperature as it was too hot, and the CNA stated that she could not feel the water temperature since she was wearing gloves. The resident stated that the CNA removed her gloves, felt the water and adjusted the temperature and the water temperature was better for the rest of the shower. The resident stated that the water felt hot on his/her right arm and showed the surveyor. There was no visible burn, discoloration or marks on the resident's arm where resident said the hot water touched. There was no assessment documented by the staff for Resident # 23's hot water complaint. No other residents reported [CONDITION(S)], injury or hot water temperatures. At 12:34 PM, the surveyor asked the Licensed Practical Nurse (LPN), who cared for the Resident # 23, for the name of which CNA provided a shower for Resident # 23. The LPN stated that a hospice CNA gave the resident a shower this morning. The surveyor requested the hospice CNA's contact information as the LPN stated that the hospice CNA was not in the facility today. Further water temperature testing done by the surveyors revealed hot water temperatures in the following units and rooms: In Unit C room 7; the sink hot water temperature was 121 degrees F, in the Upper Annex main bath; the shower hot water temperature was 134.9 degrees F, in the Lower Annex room 1; the sink hot water temperature was 139.4 degrees F, in the Lower Annex room 2; the sink hot water temperature was 138.8 degrees F, in Unit A room 104; the sink hot water temperature was 112.4 degrees F, in Unit A rooms 110 and 112; the shared bathroom sink hot water temperature was 123.4 degrees F, in Unit A rooms 114 and 115; the shared bathroom sink hot water temperature was 127.4 degrees F, Unit B room 215; the sink hot water temperature was 122.2 degrees F, and Unit B room 207; the sink hot water was 120.8 degrees F. According to the above referenced Time and Temperature Relationship to Serious [CONDITION(S)], these temperatures are well above the safe temperatures for resident use. The water temperatures were confirmed with the LNHA as follows: At 2:15 PM, the LNHA calibrated his thermometer in the presence of the surveyor. At 2:18 PM, the surveyor and the LNHA checked Unit C room 13 sink hot water temperature, and the surveyor's thermometer read 143.3 degrees F and the LNHA's thermometer read 143.6 degrees F. At 2:25 PM, the surveyor and the LNHA checked the shower hot water temperature in Unit C's main bath, and the surveyor's thermometer read 134.1 degrees F and the LNHA's thermometer read 134.1 degrees F. At 2:33 PM, the surveyor and the LNHA checked the sink hot water temperature in Unit B room 215, and the surveyor's thermometer read 123.2 degrees F and the LNHA's thermometer read 123.8 degrees F. At 2:36 PM, the surveyor and the LNHA checked the sink hot water temperature in Unit A room 114 and 115, and the surveyor's thermometer read 123 degrees F and the LNHA's thermometer read 123.1 degrees F. At 2:40 PM, the surveyor and the LNHA checked the sink hot water temperature in Unit A room 112, and the surveyor's thermometer read 120.4 degrees F and the LNHA's thermometer read 120.6 degrees F. At 2:42 PM, the surveyor and the LNHA checked the sink hot water temperature in Lower Annex room 1, and the surveyor's thermometer read 140 degrees F and the LNHA's thermometer read 140.5 degrees F. At 2:47 PM, the surveyor and the LNHA checked the sink hot water temperature in Lower Annex room 2, and the surveyor's thermometer read 139.7 degrees F and the LNHA's thermometer read 138.7 degrees F. At 2:50 PM, the LNHA stated that he was verbally informed by the MD that the MD adjusted water temperatures over the past weekend as residents complained that the water temperature was cold. The LNHA stated that the MD said that he adjusted it to the highest setting. At 2:53 PM, the surveyor and LNHA went to observe the boiler and the boiler was set to the highest setting of very hot. The LNHA adjusted the setting from very hot to a setting of low. The LNHA stated that it should take 2 hours until the temperature adjusts back to normal at a range of no higher than 110 degrees F. At 3:02 PM, the surveyor interviewed the House Keeping Director (HKD) who was covering for the MD today. The HKD stated that no one complained about water temperatures today and that there was no documentation of complaints of water temperature this weekend and why the temperature was adjusted. The HKD stated that the MD filled out the monthly water temperature logs dated May 4, 2022, May 11, 2022, May 18, 2022 and June 1, 2022, which was provided to the surveyor and revealed 110 degrees F for each of the 53 rooms checked for water temperature for those four weeks. The HKD stated that the facility will not use hot water until this is resolved. At 3:40 PM, the HKD stated that there were no maintenance books on all units with documentation of concerns because at this time the process is that if there are any issues, it is communicated verbally. At 4:15 PM, the surveyor interviewed the Hospice CNA, who cared for Resident # 23. The Hospice CNA stated that as she got the resident ready for the shower today, the water seemed hot as she touched it with her arm, she turned on the cold water and made the temperature more comfortable. The Hospice CNA stated that the resident did not complain of hot water and only asked for the water to be a little warm. The Hospice CNA stated that she did not report the hot water temperature to anyone because she was able to adjust the temperature with use of the cold water. The surveyor reviewed the Safe Water policy and procedure, dated 1/1/22, which revealed that the water temperatures will be set to a temperature of no more than 110 degrees F, and that the maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. On 6/7/22 at 10:35 AM, the surveyor interviewed the MD who stated that on Sunday 6/5/22, a nurse called him and said that the water temperature was cold, and the pilot light was out. The MD stated that he came into the facility and re-set the pilot and it turned on. The MD stated that he set the boiler to just under the hot setting and stated that he left the facility without documenting anything or following up on the water temperature. The MD stated that Monday, 6/6/22 at 5AM, he came back to check the boiler, the pilot light was on, and the setting was set to just under hot setting. He stated that the temperature of the water read 110 degrees F and he checked Unit B and Unit C, but did not document this anywhere. The MD stated that on Tuesday 6/7/22, the nurse called to tell the LNHA and stated that the water was cold again, this was also not documented anywhere and the LNHA did not state this. The MD stated that a plumber came on Tuesday 6/7/22, and the MD stated that the plumber must have set the boiler to very hot. The surveyor requested documentation of the plumber visit and there was no documentation provided to the surveyor. The facility's failure to monitor and follow up on water temperatures after adjusting the boiler setting, placed Resident # 23, as well as all other residents, at risk for unsafe water temperatures, which resulted in an Immediate Jeopardy situation. On 6/7/22 at 5:00 PM, the surveyors met with the LNHA, Director of Nursing, and Clinical Liaison to inform them of the IJ. An IJ template was emailed to the LNHA at 5:07 PM. On 6/8/22 at 10:59 AM, the LNHA submitted the removal plan and the surveyor verified the plan that the facility which revealed that the facility lowered the water heater dial, water temperatures were checked on all sinks and bathroom/shower stalls in the whole building every 30 minutes and will be documented in the water temperature log for 30 days, all staff was in-serviced regarding water temperature safety, MD/designee was educated regarding checking water temperatures when a water temperature setting is adjusted to ensure that it is within a safe temperature level, maintenance communication policy revision for a communication book to be on each unit, separate work order form will be utilized for any immediate issue, monthly audits on all the water temperatures taken daily and monthly QAPI on water temperatures x 3 months and quarterly thereafter. The non-compliance for F689 remained on 6/16/22 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. NJAC 8:39-31.7 (h)

COMPLAINT # NJ 3 CENSUS: 56 SAMPLE: 1 Based on observations, interviews, review of the Medical Record (MR), and other pertinent facility documentation on 5/26/2020, it was determined that the facility failed to ensure a resident with moderate cognitive impairment, who was at risk for elopement, had a history of elopement attempts, and a known history of exit seeking behavior, was appropriately monitored and supervised to prevent elopement or exiting the building, as well as failed to secure the resident's window for safety to prevent accidents for 1 of 1 residents sampled, (Resident #1). On 5/18/2020, Resident #1 was observed by the Recreation Director (RD) hanging out the second floor window, the RD and the Licensed Practical Nurse (LPN #1), redirected the resident, however, the nurse failed to check the window for safety and ensure that the window was secured shut. The resident was able to open the unsecured window, tied sheets together, and subsequently fell to the ground from the second-floor and was sent to the emergency room (ER) via 911 and admitted for a [CONDITION(S)]. This deficient practice placed Resident #1 and all other residents with cognitive impairment who were at risk or who had a known history of wandering and/or elopement, in an Immediate Jeopardy (IJ) situation. The IJ was identified on 5/26/2020 at 5:48 p.m., when the Administrator and the Director of Nursing (DON), were notified of the IJ and were provided the IJ template. The IJ ran from 5/18/2020, through 5/26/2020 at 12:00 p.m., and was lifted when the facility provided an acceptable Removal Plan. This deficient practice was further evidenced by the following: 1. According to the Admission Record, Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Age-Related Cognitive Decline, Cerebral Infarction, Major Depressive Disorder, [CONDITION(S)], and Lack of Coordination. Review of the Minimum Data Set (MDS), an assessment tool dated 5/4/2020, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10/15, indicating Resident #1 had moderate cognitive impairment. The MDS also indicated Resident #1 needed limited assistance for Activities of Daily Living (ADLs). Review of the Care Plan dated 5/11/2020, revealed Resident #1 was an elopement risk and a wanderer, related to impaired safety awareness. The Goals listed included but were not limited to: The resident's safety will be maintained through the review date. The resident will not leave the facility unattended through the review date. The Target date was 8/9/2020. The interventions listed included but were not limited to: Assess for fall risk. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Also listed under Interventions, the resident's triggers for wandering/eloping are agitation. The resident's behaviors are de-escalated by gently redirecting. Further review of the Care Plan dated 5/11/2020, revealed Resident #1 had a potential to be physically aggressive and takes things off the wall when frustrated, related to anger. The Goals listed included but were not limited to: The resident will demonstrate effective coping skills through the review date. The resident will not harm self or others through the review date. The interventions listed included but were not limited to: Administer medications as ordered. Monitor and document for side effects and effectiveness. Analyze times of day, places, circumstances, triggers and what de-escalates behavior and document. According to the Admission Review Sheet dated 4/28/2020, Resident #1 had left the Assisted Living (AL) Facility he/she was living in Against Medical Advice (AMA), because they would not let him/her go out to smoke. They also documented the resident was on 1:1 for monitoring. Review of the facility's progress notes dated 5/4/2020 at 9:15 p.m., the nurse documented the following: Resident seen walking out the door to the parking lot, nurse and recreation aide followed resident and tried to redirect him back to the facility, resident refused saying I'm going to the bus stop, I got things to do today. The nurse and recreation aide followed the resident to the street and continued to encourage the resident to come back to the facility. After a few minutes the resident returned to the facility. The doctor was notified of the resident's behavior and gave an order to send the resident to the hospital for an evaluation. The resident was admitted to the hospital for Altered Mental Status and was readmitted to the facility on [DATE]. Review of the facility's progress notes dated 5/10/2020 at 6:07 p.m., the nurse documented the following: Patient wandering, still risk of elopement, medicated for anxiety and aggression . will continue to monitor. Review of the facility's progress notes dated 5/14/2020 at 9:00 a.m., the nurse documented the following: The resident was walking around the room and stated, I'm leaving right now, I have a taxi coming it's almost here Resident aggressive and agitated when approached unable to redirect.[MEDICATION(S)] given as ordered-effective. At 11:00 a.m., the nurse reported the resident was aggressive towards the staff but redirectable. Safety and fall precautions maintained. At 1:00 p.m., the resident was alert with noted confusion, continues to yell and curse at the staff with effective redirection. Safety and fall measures in place. At 4:00 p.m., the resident was extremely aggressive, banging on door demanding to leave with all person [sic] belongings packed. The nurse was unable to effectively redirect the resident and documented aggressive when approached and attempts at verbally engaging resident ineffective. Prn (as needed) [MEDICATION(S)] (an antianxiety medication) given - continues to walk around unit but no aggression noted. At 6:00 p.m., the resident attempted to leave the facility . redirected by the staff effective. Short intervals of calmness achieved with verbal engagement between resident and staff. Constant monitoring maintained. Remains alert and stable. Review of the facility's progress notes dated 5/15/2020 at 1:27 p.m., the DON documented she spoke with the Psych Nurse Practitioner (NP) about Resident #1's medications and the following recommendations were made and will be reviewed with the Primary Medical Doctor. Discontinue [MEDICATION(S)] and [MEDICATION(S)], increase [MEDICATION(S)] and standing [MEDICATION(S)]. Review of the facility's progress notes dated 5/15/2020 at 2:22 p.m., the DON documented the resident pulled the fire alarm and stated they did not take me out as fast as I wanted. I don't care that this was wrong. I will do it again if I do not get [MEDICATION(S)]. The DON counseled the resident on safety and how to make his needs known in a non-dangerous manner. Review of the facility's progress notes dated 5/15/2020 at 6:45 p.m., LPN #1 documented Resident #1 was sitting in the common area (dayroom) looking out the second floor window when the resident became agitated and stated, I'm waiting for the police to come. LPN #1 then heard a loud noise and observed Resident #1 with the window open and ejecting his/her limbs out of the window and cursing at staff members who were down in the parking lot below. The LPN attempted to redirect the resident, and documented was not easily redirected and became harmful to himself/herself. The nurse called the doctor to inform him of the resident's state. The doctor ordered to send the resident to crisis for an evaluation. There was no documentation indicating the nurse checked the window for safety or secured the window shut. According to the progress notes the nurse documented Resident #1 returned to the facility on [DATE] at 6:55 a.m., with diagnoses of Dementia and Agitation. She also documented, the resident was alert with confusion. Vital signs were checked, and the nurse reported: Will continue to monitor. According to the Facility's Reportable Event (FRE) , reported to the NJ Department of Health (NJDOH) on 5/20/2020, with a Date of Event of 5/18/2020, and a Time of Event of 6:45 p.m., indicated that prior to the event Resident #1 was in his/her room, the resident tied bed sheets together into a rope and tried to climb out of the window. The resident was found outside on the ground, sitting upright against the wall of the building by the therapy room. The resident was crying out for help. Resident was alert, awake and verbally responsive with clear speech. Several sheets tied in knots were underneath the resident. Review of the nursing progress notes attached to the FRE, indicated on 5/18/2020 at 5:00 p.m., the nurse saw the resident in the hallway and the resident stated to the nurse I want to get out of here, I will pull the fire alarms or call 911. The nurse documented she redirected the resident and the resident returned to their room. At 6:00 p.m., the nurse documented nurse was made aware by Activity Director that resident (Resident #1) was attempting to eject his/her limbs out of room window. She further documented when approached and asked, what are you doing, it is not safe opening up the window. The resident replied, I'm getting the F out of here. The staff documented that they were able to redirect the resident and the resident was encouraged to come out of the room, however, the resident declined. The nurse documented upon staff exiting room resident noted not in window area. At 6:45 p.m., the nurse documented she received a call from the therapy department who informed her that Resident #1 was outside on the ground. Staff immediately responded and 911 emergency were notified. There was no documentation indicating the nurse checked the window for safety or secured the window shut. According to the FRE Conclusion undated, the DON documented the following: Resident sustained a hip fracture from the [sic] trying to leave the building by climbing out of the window using tied sheets which was not anchor [sic] properly and caused him/her to fall to the ground together with the tied sheets. During a facility tour on 5/26/2020 at 10:30 a.m., accompanied by the DON and the Assistant Director of Nursing (ADON), the surveyor's observation of Resident #1's room revealed a semi-private room with 2 single beds. The DON reported Resident #1 does not have a roommate secondary to his behavior. Three windows were observed in the center of the room which were grouped together. The center window had an air conditioner in place and was sealed shut by a board screwed to the edge of the window and the air conditioner was secured by screws in place on the upper and lower edges of the window. The window on the left side was observed closed with 2 screws approximately 3 inches above the window and a screw and bolt above the 2 screws. The window on the right had 2 metal brackets in place above the lower window on each side which were held in place with 2 screws which prevented the window from opening at all. During the tour on 5/26/2020 at 10:35 a.m., the DON stated, Resident #1 opened the window by using a knife as a screwdriver to open the window, however, no knife was found. During an interview on 5/26/2020 at 11:49 a.m., the Recreation Director (RD) reported, on 5/18/2020 between 6:30 and 7:00 p.m., she was sitting in the B wing dayroom and observed through the window on C wing Resident #1 he/she stuck his/her head and arms out of the window The window was open about one foot, twelve inches. The RD stated she immediately went to the resident's room. From the doorway she said to Resident #1, don't stick your head out it's not safe. The resident closed the window and stayed in the room. The RD reported the resident was agitated and stated aggressively, don't tell me what to do. The RD reported the incident to the nurse on the unit. I told them [LPN #1 and the Certified Nursing Assistant (CNA #1)] the resident had his head and arms out of the window and he was very agitated. The RD reported she then went to the room with the nurse and the CNA and the resident was still in the room and was still agitated and yelling saying, respect my privacy. When the RD left, the nurse and the CNA were still with the resident. The RD stated the window was closed when she left. During an interview on 5/26/2020 at 1:10 p.m., the Director of Social Services (DSS) reported, Resident #1 was initially on the 1st floor on an unlocked unit, however, he/she attempted several times to exit the building. In addition, the resident was able to walk around, and people were afraid because he/she would talk about hurting others, therefore, the resident was moved to the 2nd floor locked unit. The DSS also stated, she did not feel Resident #1 was safe to make decisions because of his/her aggression. During a phone interview on 5/26/2020 at 2:32 p.m., LPN #1 reported, she was notified by the RD that Resident #1 was waving his/her arms out of the window. She reported when she went to the room the windows were closed and she observed screws in place above the window. I saw screws in place on the left side, so I did not try to open the windows to see if there were any issues with the windows. When she left, Resident #1 was in their room on the bed and appeared calm, the resident stated to LPN #1, he/she understood, and was not going to do anything and the resident stated, I'm okay. According to LPN #1 she paged maintenance to check the windows, however, maintenance never responded to the page and she did not call maintenance again. According to LPN #1, she rechecked the resident about 15 minutes later and observed the resident in their room washing clothes. According to LPN#1, she did not send Resident #1 to crisis because the resident never stated he/she wanted to leave or talk about hurting himself/herself and the resident was calm when he/she left. She later was alerted by the therapy department that the resident was outside. She called 911 then went outside to assess the resident. During an interview on 5/26/2020 at 11:03 a.m., the Maintenance Director (MD) reported that he was not in the building on 5/18/2020, when Resident #1 climbed out of the window since his shift ended at 3:00 p.m., however, he was called to return to the facility around 6:00 p.m. They said there was an accident here. Someone had jumped out of the window and I was called to come fix the window. According to the MD the resident had 3 windows in his room grouped together the MD stated, the resident jumped out the window on the right side, the window was wide open, glass was not broken, he/she forced the screws out. When he returned to the facility on [DATE], he observed the window in Resident #1's room on the far right to be wide open which was over 12 inches. The MD also reported that prior to the incident there was 2 L brackets on the window, one on each side. When he arrived after the incident one L bracket was bent, the other one was off completely. According to the MD all windows on the second floor are checked monthly by the maintenance department, however, the MD reported no logs were kept of the inspections. In addition, the MD reported L brackets were added to Resident #1's windows about 1 month prior to the accident since the bolts were loose. Review of the Facility document dated 4/30/2020, titled Elopement Risk Assessment Form for Resident #1, dated 4/30/2020, under Definitive Risk Factors: Marked Yes for the questions: Is the resident cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits, disoriented) Under Summary of Assessment, The nurse documented; Resident is not at risk for elopement at this time. Under Scoring: Three or more Resident status/Potential Risk Factors and/or one or more Definitive Risk Factors indicate a resident at risk for elopement. During an interview on 5/29/2020 at 10:00 a.m., the DON verified that the Elopement Risk Assessment Form completed on 4/30/2020, was completed incorrectly by the nurse because Resident #1 did have one Definitive Risk Factor. A review of the facility's policy titled Elopement dated 9/18/2019, included the following under Policy: It is the objective of this facility to ensure the safety and protection of wandering residents by preventing their exit from the building. A review of the facility's policy undated, titled Hazardous Areas, Devices and Equipment, under Policy Statement: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Under Identification of Hazards section 1., A hazard is defined as anything in the environment that has the potential to cause injury or illness. Section 1.d. Open area or items that should be locked when not in use. Section 1.k. Disabled locks, latches or alarms. Under Assessment and Analysis of Hazards: section 2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. Under section 3. Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities, mood and health treatments (e.g., medications). Resident #1 was observed by the Recreation Director (RD) hanging out the window and she reported the unsecured window to the nurse on the unit, however, the nurse failed to check the window for safety and the resident was able to open the unsecured window, tied sheets together, and exited the building, and subsequently fell to the ground from the second-floor and was sent to the emergency room (ER) via 911 and admitted for a [CONDITION(S)]. This deficient practice placed Resident #1 and all other residents with cognitive impairment who were at risk or who had a known history of wandering and/or elopement, in an Immediate Jeopardy (I) situation. The IJ was identified on 5/26/2020 at 5:48 p.m., when the Administrator and the Director of Nursing (DON), were notified of the IJ and provided the IJ template. The IJ ran from 5/18/2020, through 5/26/2020 at 12:00 p.m., and was lifted when the facility provided an acceptable Removal Plan. A revisit to verify the Removal Plan occurred on 5/29/2020. N.J.A.C. 8:39-33.1(d)

Based on observation, interview, and record review it was determined that the facility failed to consistently provide interventions to prevent the development of a pressure ulcer for 2 of 4 residents (#2,12) reviewed for pressure ulcers. Resident #2 developed a Stage II pressure ulcer behind the right ear from the use of oxygen tubing. The findings were based on the following: 1. On 10/22/12 at 7:30 a.m. during the initial tour with a staff nurse Resident # 2 was observed in bed asleep receiving oxygen via a nasal cannula. There was gauze padding around the oxygen tubes that rested on and behind the ears. The staff nurse stated that the resident had a Stage II pressure ulcer behind the right ear. The staff nurse stated that the resident developed the wound in the facility because of the oxygen tube positioned behind the ear. On 10/22/12 at 11 a.m. the surveyor reviewed the resident's medical record which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurses note dated 8/19/12 at 10 a.m. revealed "resident with open area right posterior ear at 12 o'clock position-prob (secondary) to O2 tubing." A physician's orders [REDACTED]." The resident had a care plan for pressure ulcer risk dated 6/12/12, however, there was no intervention listed regarding the risk prevention of a pressure ulcer due to nasal cannula use. The resident was under the care of a wound care specialist for the above mentioned wound as well as other wounds. On 10/11/12 the wound care specialist noted, in regard to the right posterior ear, "WOUND DETERIORATED DUE TO NASAL CANNULA: PLEASE MAKE SURE THERE IS TREATMENT ON AT ALL TIMES." When the wound care specialist assessed the wound on 10/4/12 the wound measured 0.3 x 0.2 x 0.1 cm. When measured on 10/11/12, the wound measured 0.9 x 0.5 x 0.2 cm. The surveyor discussed the avoidable pressure ulcer with the nurse on 10/22/12 at 11:15 a.m. The staff nurse did not provide any additional explanation regarding the wound. 2. The surveyor observed the nurse perform a wound treatment on an open area on the left buttock of Resident #12 on 10/25/12 at 10 a.m. The surveyor observed 2 open areas on the left buttock when the nurse removed the soiled dressing. The surveyor asked the nurse what area she was treating. The nurse replied by pointing to one area. The nurse then stated there was a new open area adjacent to the original site. The surveyor observed that the nurse did not measure the new opening. She applied an antibiotic ointment to the original site, as ordered, and applied the ointment to the second, newer site. The surveyor interviewed the treatment nurse on 10/25/12 at 12:25 p.m. regarding the procedure followed when a new pressure sore is first observed. The nurse replied [MEDICATION NAME] (antibiotic ointment) is applied and "wait for the doctor to come in to see it." The surveyor asked if the wound should be measured and documented. The nurse replied she already measured the wound, but did not yet document it. The surveyor asked Resident #12 if the nurse came back to the room to remove the dressing to measure the wound. The resident said the nurse had not been back to remove the dressing on the wound. The surveyor reviewed the medical record of Resident #12 on 10/22/12. The last full MDS, an assessment of the resident's capabilities, was conducted by the facility on 8/19/12. This assessment showed that the resident was alert and oriented. This was confined by the surveyor during interviews and observations of Resident #12. There was a physician's orders [REDACTED]. The surveyor observed a foam cushion on the bedside chair on 10/22/12 through 10/25/12. The Physical Therapist confirmed to the surveyor that the cushion was made of foam (11/25/12 at 10:30 a.m.). The surveyor asked the resident if this was the same cushion that was given to him in August. He replied this was the original cushion. The surveyor showed the nurse the foam chair cushion that was in use. The nurse replaced the foam cushion with a gel cushion. NJAC 8:39-27.1(a)