Every finding on record at Crest Haven Nursing and Rehabilitation Center

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to revise an individual Comprehensive Care Plan for a resident with a change in code status. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed and was evidenced by the following:On [DATE] at 10:05 AM, the surveyor observed Resident #2 in the activities room lying in a recliner. The resident interview was not possible due to a diagnosis of dementia (memory loss). On [DATE] at 12:21 AM, the surveyor reviewed the medical record for Resident #2. A review of the admission Record (an admission summary) reflected The Resident was admitted to the facility with medical diagnoses that included but were not limited to; dementia, anxiety disorder, and protein-calorie malnutrition (inadequate intake of protein and calories). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of the Resident's care dated [DATE], indicated that Resident #2 had short and long-term memory deficits. The Resident was severely impaired for decision making and required maximum assistance for most activities of daily living (ADLs). A review of the resident's Order Summary Report (OSR), dated [DATE], included the following physician's orders (PO) to consult Serenity for evaluation and treatment, do not resuscitate (DNR), and do not intubate (DNI). A review of the Individualized Comprehensive Care Plan (ICCP) included a focus area dated [DATE], for an Advanced Directive of Full Code. Interventions included: code status will be reviewed quarterly with a resident and/or responsible party, cardiopulmonary resuscitation (CPR), [a lifesaving technique to restart a person's heartbeat and breathing], will be performed as ordered, follow facility protocol for identification of code status, keep the family informed of change in condition, and provide emotional support as needed. The ICP was not updated to reflect the physician's order regarding the change in the Resident's code status from Full code to DNR and DNI. A review of the Progress Notes (PN) included a nurse's note (NN), dated [DATE] at 10:26 PM, which included that Resident #2 was admitted into Serenity Hospice Care with new orders, the Resident's son was notified and was agreeable with recommendations and that the doctor was made aware. On [DATE] at 12:05 PM, the surveyor interviewed the Certified Nursing Assistant (CNA), [NAME] Salfi, who stated that the Resident had recently change to hospice care and confirmed that the hospice staff provided care in the mornings. On [DATE] at 12:27 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), Jamirah Smiley, who confirmed that a change of code status for hospice care required updating the care plan to reflect changes so that staff can provide the appropriate care. On [DATE] at 12:44 PM, the surveyor interviewed the first floor Unit Manager (UM), [NAME] Kanderson, LPN, who explained that for hospice residents, a Physician Orders for Life Sustaining Treatment (POLST) {medical orders for preferences regarding life-sustaining treatment}, is completed with the resident and family and signed by the doctor. The UM stated that for a change of code status the Resident's care plan must be updated immediately to ensure that the correct care is administered should an emergency occur. The UM further explained that she was responsible for updating and ensuring the accuracy of ICCP when a resident code status changes. However, Resident #2's care plan was not updated. On [DATE] at 12:52 PM, the surveyor interviewed the Director of Nursing (DON), Mychelle [NAME], who confirmed that when an order is received for hospice and a change in code status, the care plan is immediately updated. However, Resident #2's, care plan did not reflect a change of code status as ordered on the OSR. The facility policy Care Plans, Comprehensive, Person-Centered, reviewed/revised date 8/2025, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. NJAC 8:39-27.1(a)

Complaint #2563285 Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to develop and implement an individualized comprehensive care plan (ICCP) for a resident who was non-compliant with receiving treatments and meals prepared in the facility. This deficient practice was identified for 1 of 3 residents sampled (Resident #1) and was evidenced by the following:On 10/30/2025 at 8:30 AM, the surveyor reviewed Resident #1's medical record.A review of the admission Record face sheet reflected the resident had diagnoses that included but not limited to pressure ulcer of the sacral region (stage 4), malignant neoplasm of the rectum (cancer of the rectum), and fracture of the right fibula. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/28/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderately impaired cognition. The Resident Mood Interview indicated that the resident had little interest or pleasure in doing things. Further review of the MDS revealed the resident had one unhealed stage 4 pressure ulcer (severe form of skin damage from prolonged pressure).A review of the Order Summary Report (OSR) with orders active as of 7/9/2025, revealed the following: - Cleanse sacral wound with NSS (normal saline solution), pack with packing strip in NSS, and apply CDD (conventional daily dressing) every day and evening shift for wound care. Use until orders are in place for wound started on 6/25/2025.- Estrace vaginal cream 0.1 milligram/gram (Estradiol Vaginal), insert 0.5 gram vaginally at bedtime for itching for 3 Months.- Nystatin-Triamcinolone Cream 100000-0.1 unit/gram-%. Apply to labia majora and vulva topically every day and evening shift for itching for 2 months.- Monitor for refusals with ADLs, medication administration, treatments every shift for monitoring started on 6/28/25.A review of the Treatment Administration Record (TAR) for the month of June 2025, revealed the resident's refusal of the ordered treatments on the evening shift of 6/26/2025, morning and evening shifts on 6/28/2025, and on the morning shift of 6/29/2025. A review of the Treatment Administration Record (TAR) for the month of July 2025, revealed the resident's refusal of the ordered treatments on the day and evening shifts of 7/5/2025.A review of the nursing progress notes reflected the resident's refusal of the ordered treatments on the evening shift of 6/26/2025, morning and evening shifts on 6/28/2025, and on the morning shift of 6/29/2025, and on the day and evening shifts of 7/5/2025.A review of the nursing progress notes reflected the resident's refusal of meals specifically breakfast and lunch on 6/26/2025, lunch on 6/27/2025, and dinner on 6/27/2025. The nursing progress notes dated 6/26/2025 and 6/27/2025, revealed the resident's spouse notifying the nurses in charge about the resident's preference for home-cooked food.A review of Resident #1's comprehensive care plan did not include a focus addressing the resident's refusal of ordered treatments and preference for home-cooked meals. On 10/30/2025 at 12:38 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that care plans are updated as things happen.A review of the facility-provided policy revised on August 2025, titled Care Plans, Comprehensive, Person-Centered included under Policy Interpretation: 7.c) The care planning process will incorporate the resident's personal and cultural preferences in developing the goals of care. 8.c.) Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. N.J.A.C. 8:39 - 11.2 (d)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a.) nephrostomy (a type of urinary catheter inserted through the skin into the kidney to drain urine when there is blockage) care was consistently performed and documented in accordance with a physician order; b.) nephrostomy flushing was consistently performed and documented in accordance with a physician order; c.) urine output from nephrostomy tube was consistently monitored and documented according to physician orders; d.) urine output from Foley catheter was consistently monitored and documented according to a physician order; and e.) large catheter bag (a bag used to collect urine) was consistently changed to a leg bag when the resident was out of bed according to a physician order. This deficient practice was identified for 2 of 3 residents reviewed for urinary catheter (Resident #1 and Resident #72), and was evidenced by the following: 1. On 4/8/25 at 8:30 AM, the surveyor observed Resident #1 in bed during an incontinence round with a Certified Nursing Assistant (CNA). The CNA exposed the brief which was noted to be well-fitted and dry. A nephrostomy tube was noted on the right flank side of the resident's back. The tube was labeled and dated appropriately. There was no dressing noted covering the incision site. The surveyor reviewed the medical record for Resident #1. A review of the Admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included; obstructive and reflux uropathy (a condition where normal flow of urine is blocked or flows backward from the bladder anywhere in the urinary tract) and calculus (stone) of the kidney. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/22/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated a moderately impaired cognition. The MDS further included that the resident had an indwelling catheter. A review of the Order Summary Report (OSR) revealed the following active orders as of 4/8/25: - Cleanse around right nephrostomy catheter incision site with NSS (normal saline solution), pat dry, and apply a slit 4 x 4 gauze dressing daily on day shift for wound care started on 10/15/24. - Flush nephrostomy tube daily with 10 milliliters (ml) flush on 7:00 AM to 3:00 PM shift. Apply border gauze to nephrostomy site with daily flush every day shift for nephrostomy tube care started on 12/9/24. - Monitor output and empty bag every shift from right nephrostomy tube every shift started on 8/22/24. - Document urine output every shift started on 8/22/24 and revised on 2/27/25. A review of the monthly Treatment Administration Record (TAR) for the months of October 2024 through April 2025, revealed blanks in the documentation portion for the corresponding orders from the OSR and were not addressed in the progress notes: - 10/30/24, day shift had blanks on order for cleansing of catheter, order for flushing of catheter, and order to document urine output. - 11/8/24, day shift had a blank on order for cleansing of catheter. - 11/13/24, day shift had blanks on order for cleansing of catheter, order for flushing of catheter, and order to document urine output. - 11/29/24, day shift had a blank on order for cleansing of catheter. - 11/30/24, day shift had a blank on order for cleansing of catheter. - 12/10/2024 day shift had blanks on order for cleansing of catheter, order for flushing, and order to document urine output. - 1/13/25, evening shift had a blank on order to document urine output. - 1/16/25, day shift had blanks on order for cleansing of catheter, order for flushing, and order to document urine output. - 1/22/25, day shift had blanks on orders for cleansing of catheter, order for flushing of catheter, and order to document urine output. - 2/2/25, day shift had blanks on orders for cleansing of catheter, order for flushing of catheter, and order to document urine output. - 2/26/25, day shift had a blank on orders to document urine output. - 3/11/25, evening shift had a blank on order to document urine output. - 3/29/25, day shift had blanks on orders for cleansing of catheter, order for flushing of catheter, and order to document urine output. - 4/2/25, day shift had blanks on orders for cleansing of catheter, order for flushing of catheter, and order to document urine output. A review of the individualized comprehensive care plan (ICCP) dated revised on 12/12/24, included a focus for risk of urinary retention related to kidney stone, benign prostatic hyperplasia (prostate gland enlargement), right nephrostomy tube, bladder outlet obstruction, and chronic obstructive pyelonephritis (kidney infection with blockage of the urinary tract). The goal was for the resident to be free from signs and symptoms of retention. Interventions included to administer the resident's medications per physician orders and to obtain laboratory tests as ordered and notify the physician. Another focus area the resident was at risk for infection due to the nephrostomy catheter that requires Enhanced Barrier Precaution (EBP) (an infection control strategy to reduce transmission of multidrug-resistant organisms in nursing homes). The goal for this focus was for the resident to be free from signs and symptoms of active infections. Interventions included EBP, laboratory tests as ordered, and hand hygiene prior to and after care. On 4/11/25 at 1:39 PM, during an interview with the survey team, the Director of Nursing (DON) was asked by the surveyor what a blank in the administration record would indicate. The DON stated that a blank in the administration records indicated that the nurse did not document it. The surveyor asked the DON if a blank meant the order was not completed as ordered. The DON stated, Yes. The DON was asked by the surveyor why it was important to do catheter care and catheter flushing. The DON replied that catheter care was important to monitor for infection. The DON also stated that flushing was important to make sure the catheter was functioning properly. The DON was asked why it was important to monitor urine output, and the DON replied to make sure whatever was going in was coming out; that it was adequate. A review of facility provided policy titled Management of Indwelling Catheter revised in January 2025, did not address nephrostomy care, nephrostomy flushing, and monitoring of urine output. 40039 2. On 4/8/25 at 12:20 PM, the surveyor observed Resident #72 in the rehabilitation room. Resident #72 was observed to have their large Foley catheter bag suspended beneath the seat of their wheelchair. The Foley bag was observed to be inside of a blue privacy bag. The surveyor reviewed the medical record for Resident #72. According to the Admission Record, Resident #72 was admitted to the facility with the following diagnoses: displaced fracture of base of neck of right femur, urinary tract infection, retention of urine, and presence of urogenital implants. According to the Minimum Data Set (MDS), an assessment tool dated 3/16/25, Resident #72 had a Brief Interview for Mental Status score of 3 out of 15, which indicated severe cognitive impairment. A review of Section GG revealed that Resident #72 was dependent on staff for activities of daily living. A review Section H of the MDS revealed that Resident #72 had an indwelling catheter. A review of Section I revealed that Resident #72 had active diagnoses of a urinary tract infection and retention of urine. A review of the Order Summary with an order date range of 1/1/25-4/30/25, revealed the following physician's order (PO) for Resident #72: A PO dated 3/10/25, to change drainage bag to leg bag every day shift when out of bed (OOB) and change back to large drainage bag at night, every shift. A review of the ICCP included a focus area that the resident had an indwelling urinary catheter related to urinary retention. Interventions included to: change urinary collection bag as needed/ordered, and report if there was a change in amount, color, or odor of urine. On 4/10/25 at 10:38 AM, Resident #72 was observed seated in a high back wheelchair in the [NAME] Solarium attending an activity after completing physical therapy. Resident #72 had their large catheter bag suspended from the frame under the seat of their wheelchair and enclosed in a large privacy bag. Resident #72 did not have a catheter leg bag as ordered on this observation when out of bed. On 4/10/25 at 1:39 PM, the surveyor observed Resident #72 seated in their wheelchair in the [NAME] Solarium. Resident #72 had a large urinary catheter bag within a privacy bag suspended under the seat of their wheelchair. Resident #72 did not have a leg bag when out of bed as per physician order on this observation. On 4/11/25 at 11:22 AM, the surveyor observed Resident #72 seated in their wheelchair in the [NAME] Solarium. Resident #72 was doing an activity. The surveyor observed Resident #72's large catheter bag inside of a privacy bag and suspended from the seat of their wheelchair. No leg bag was observed. On 4/11/25 at 11:25 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) assigned to Resident #72. LPN #1 told the surveyor that she had worked with Resident #72 a couple of times. The surveyor asked Resident #72 if they were supposed to have a leg bag when out of bed. LPN #1 told the surveyor I assume it would be done by the nurse. I will check the order and see if it should be changed to a leg bag. LPN #1 then went into the computer and checked the order for Resident #72. LPN #1 then told the surveyor, Yes, they should have a leg bag when out of bed. On 4/11/25 at 1:39 PM the surveyor conducted an interview with facility's Administration which included the Licensed Nursing Home Administrator (LNHA), the Regional Staff Development Nurse, the Director of Nursing (DON), and the Administrator in training. The surveyor asked the Administration if Resident #72 was to have a urinary leg bag when out of bed. The DON told the surveyor, Yes, they should have had a leg bag if that was what the physician ordered. 3. On 4/8/25 at 9:26 AM, the surveyor conducted a record review for Resident #72. Resident #72 had the following active physician order: Document urine output every shift. Start date: 3/10/2025. On 4/8/25 at 1:25 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #72. A review of the 3/1/2025-3/31/2025 Treatment Administration Record (TAR) revealed that the facility failed to document urine output for Resident #72 on the following days and shifts: 3/12/25 day, 3/14/25 night, 3/16/25 evening, 3/17/25 day, 3/20/25 day, and 3/26/25 day shift. A review of the 4/1/2025-4/30/2025 TAR revealed the facility failed to document urine output on the following days/shifts: 4/3/25 night and 4/5/25 evening. On 4/11/25 at 11:25 AM, the surveyor conducted an interview with LPN #1. LPN #1 told the surveyor she had worked with Resident #72 a couple of times. The surveyor told LPN #1 that Resident #72 had a physician's order to document urine output every shift. The surveyor then asked LPN #1 when urine output should be documented. LPN #1 told the surveyor, It should be documented every shift. LPN #1 further explained that she usually does it at the end of her shift. The surveyor asked LPN #1 if the TAR should have any blanks and LPN #1 responded, No. On 4/11/25 at 1:39 PM, the surveyor conducted an interview with facility's Administration which included the Licensed Nursing Home Administrator (LNHA), the Regional Staff Development Nurse, the Director of Nursing (DON), and the Administrator in training. The surveyor asked what a blank on the TAR would indicate? The DON told the surveyor a blank on the TAR indicated that the nurse did not document it. The surveyor then asked the DON if a blank would mean it was not completed as ordered. The DON stated, Yes. The surveyor then asked the DON why it was important to monitor urine output. The DON replied to make sure whatever was going in was coming out, and that it was adequate. On 4/14/25 12:28 PM, the surveyor reviewed the 4/1-4/30/2025 TAR. The TAR revealed that Resident #72 did not have urine output documented by nursing staff on the following shifts: 4/11/25 evening shift and 4/12/25 day shift. A review of the facility's Management of Indwelling Catheter policy dated revised 1/2025. The policy did not include urinary leg bags or monitoring urinary output. NJAC 8:39-19.4(a)5; 27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations. This deficient practice was identified for 1 of 5 residents (Resident #16) reviewed for unnecessary medications, and was evidenced by the following: On 4/10/25 at 10:40 AM, the surveyor observed Resident #16 in bed. The resident stated to the surveyor they were taking pain medications because they had three different types of cancer. The resident further explained acetaminophen (Tylenol) usually did not work and after taking it, they would still be in pain. The resident had tried other pain medications like opioids with some success. The surveyor reviewed Resident #16's medical records. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included; depression, rheumatoid arthritis (chronic inflammation of the joints), malignant neoplasm of the isthmus uteri (cancer of the uterus) ,and secondary malignant neoplasm of retroperitoneum and peritoneum (cancer in the abdominal cavity that spread there from a primary cancer in another part of the body). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/26/25, reflected that the resident's Brief Interview for Mental Status (BIMS) score was 11 out of 15, which indicated that the resident's cognition was moderately impaired. A further review of the MDS revealed the resident in the last five days had received as needed pain medication or had been offered and declined. In addition, during the pain assessment interview, the resident revealed they frequently had pain and it occasionally effected their sleep. A review of the Medications section of the MDS revealed the resident was taking opioid pain medication during the last seven days or since admission. A review of the Order Summary Report (OSR) (physician's order sheet) with order date range of 3/1/24 to 12/31/24, revealed multiple orders for pain medications. A physician's order (PO) dated 3/18/24, for acetaminophen 325 milligrams(mg); give 2 tablets by mouth every six hours as needed for pain. A PO dated 3/23/24, for ibuprofen 600 mg; give 1 tablet by mouth every six hours as needed for mild pain. A PO dated 3/23/24, for oxycodone 5 mg; give 1 tablet by mouth every four hours as needed for moderate-severe pain related to unspecified osteoarthritis; pain in unspecified knee. A review of the August 2024, September 2024, October 2024, and November 2024 electronic Medication Administration Records (eMAR) revealed an order dated 3/18/24, for acetaminophen 325 mg; give 2 tablets by mouth every six hours as needed for pain with a discontinued date of 11/10/24. An order dated 3/23/24, for ibuprofen 600 mg; give 1 tablet by mouth every six hours as needed for mild pain with a discontinued date of 11/10/24. An order dated 3/23/24, for oxycodone 5 mg; give 1 tablet by mouth every four hours as needed for moderate-severe pain related to unspecified osteoarthritis; pain in unspecified knee with a discontinue date of 11/28/24. A review of the Consultant Pharmacist's (CP) Pharmacist's Consult to Physician revealed the following recommendations: On 8/27/24, the CP recommended multiple as needed (PRN) medications were noted for the same or overlapping indications. Please sequence the following medication: Tylenol, ibuprofen, oxycodone, and change to mild, moderate, and severe pain respectively. On 4/11/25 at 12:46 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated she received the monthly CP's recommendations from the Director of Nursing (DON) and she was responsible to ensure the recommendations were addressed. LPN/UM #1 stated if they were nursing recommendations, she addressed them, and if they were for the physician, she contacted the physician for their response. On 4/11/25 at 2:07 PM, the survey team met with the facility's Administration. The DON stated the time it took to respond to the CP recommendations was about ten days, but should definitely be addressed prior to the next CP review. The DON acknowledged the pain medication sequencing should have been addressed immediately after the CP identified the issue and made their recommendation. A review of the facility's undated Pharmacy Consultant Policy and Procedure policy revealed . The pharmacist will report any irregularities to the attending physician and the DON, and these reports must be acted upon . The pharmacist will provide the DON with pharmacy recommendation reports on an on-going basis each month. The DON will act upon these recommendations by bringing them to the attention of the attending physician and ensuring any changes are implemented in a timely manner. NJAC 8:39-29.3

Complaint #: NJ184231 Based on interview, review of the closed medical record, and review of pertinent facility documents, it was determined that the facility failed to notify a resident's family after a change of condition. This deficient practice was identified for 1 of 21 sampled residents (Resident #178), and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #178. A review of the Admission Record face sheet (admission summary) revealed the resident was admitted to the facility with diagnoses including; dementia (a decline of cognitive function) and primary hypertension (high blood pressure). A review of the Progress Notes revealed the following: On 1/20/24 at 6:09 AM, the resident was feeling warm and was noted with a non- productive cough. There was no documentation that the family was notified. On 1/22/25 at 5:26 PM, the resident received Tylenol for a temperature of 101 degrees Fahrenheit, was flushed, warm to the touch, and was unable to verbalize symptoms. There was no documentation that the family was notified. On 1/23/25 at 10:38 AM, nursing received a call from the family stating the resident had a visitor that informed the family the resident was sick and questioned why they had not been notified. During an interview with the surveyor on 4/8/25 at 9:47 AM, the Licensed Practical Nurse (LPN #2) said that when there was a change in the resident's condition such as a temperature, a cough, a change in mental status, or any other symptom that would be different from the resident's normal, the family was notified. LPN #2 also said that the notification to the family was documented in the resident's Progress Notes. During and interview with the surveyor on 4/8/25 at 10:01 AM, the Director of Nursing (DON) said when there was a change in a resident's status, the nurse completed an assessment, called the doctor, notified the family, and documented in the Progress Notes. When asked if Resident #178's family was notified of their change in condition in January of 2025, the DON said she could not find any documentation that the family was notified and confirmed they should have been. A review of a facility provided Notification of Change policy dated revised 1/2025, included . The facility must inform the resident, consult with the resident's family and or notify the resident's family member or legal representative when there is a change requiring such notification . NJAC 8:39-13.1(c)

Complaint #: NJ184231 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) ensure there was a physician's order (PO) for oxygen administration and b.) administer nebulizor therapy (a method of delivering medications to the lungs by inhaling a mist created by a nebulizer) consistently according to the physician order. This deficient practice was identified for 2 of 3 residents reviewed for respiratory care and services(Resident #178 and Resident #44), and was evidenced by the following: A review of Resident #178's electronic Medical Record (EMR) revealed two progress notes. On 1/23/2025 at 10:45 AM, and on 1/23/25 at 11:00 AM, which indicated the resident was currently on 2 liters of oxygen. A review of Resident #178's Admission Record face sheet (an admission summary) revealed they were admitted to the facility with diagnoses which included; dementia (a decline of cognitive function) and primary hypertension (high blood pressure). A review of Resident #178's Order summary report dated 1/1/2025- 1/24/2025, did not include a PO for oxygen. During an interview with the surveyor on 4/8/25 at 9:47 AM, the Licensed Practical Nurse (LPN #2) said residents on oxygen should have a physician's order. When asked about a resident in respiratory distress LPN #2 said, if they do not already have an order for oxygen, they would used nursing interventions and placed the resident on oxygen at 2 liters per minute then call the doctor for further instructions and placed orders in the computer. During an interview with the surveyor on 4/8/25 at 10:01 AM, the Director of Nursing (DON) said that Resident #178 should have had an order for oxygen. The DON was unsure of when the resident was placed on oxygen and after reviewing the resident's EMR she stated, She didn't have any orders for oxygen but should have. A review of a facility policy titled Oxygen Administration with a revised date of 1/2025, revealed under . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 51337 2. On 4/7/25 at 10:06 AM, during the initial tour of the facility, the surveyor observed Resident #44's nebulizer on top of their bedside table. The resident stated that they used the nebulizer a couple of times a day. The surveyor reviewed the medical record for Resident #44. A review of the Admission Record face sheet revealed Resident #44 was admitted to the facility with diagnoses which included; acute respiratory failure with hypoxia (deficient oxygen in the body) and an abscess of the lung with pneumonia (a collection of pus in the lungs). A review of the resident's most recent Minimum Data Set (MDS), an assessment tool dated 3/4/25, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated a mildly impaired cognition. The MDS also reflected that the resident received respiratory treatment which included continuous oxygen therapy. A review of the April 2025 Order Summary Report included the following orders: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083% (Albuterol Sulfate) one application inhaled orally every 6 hours for shortness of breath related to acute respiratory failure with hypoxia and bacterial pneumonia ordered on 2/25/2025 and started on 2/26/2025. Oxygen at 4 liters per minute via nasal cannula (a device used to deliver oxygen) as needed for oxygen saturation (level) of 88% or less. A review of the corresponding Medication Administration Record (MAR) in February 2025 revealed that nebulization on the following dates and times was not signed administered: On 2/26/25 at 6:00 PM. On 2/27/25 at 12:00 AM. On 2/28/25 at 12:00 PM. A review of the individualized comprehensive care plan initiated on 2/25/25, reflected a focus for self-care deficit due to recent hospitalization for pneumonia, acute hypoxic respiratory failure, and oxygen use. The interventions included the resident required assistance to complete activities of daily living. On 4/11/25 at 1:36 PM, during an interview with the survey team, the Director of Nursing (DON) stated that if the MAR was not checked then it was basically not done. A review of facility provided policy titled Oxygen Administration revised in January 2025, did not address nebulization therapy. NJAC 8:39 - 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications used in the facility were labeled and stored in accordance with professional standards to preserve their integrity. This deficient practice was observed in 1 of 2 medication storage rooms (East wing) inspected and was evidenced by the following: On 4/7/25 at 10:42 AM, the surveyor, in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM #1), inspected the East Unit Medication Room. Observed on the counter was two one-liter opened and removed from the protective packaging Intravenous (IV) solutions for dextrose 5% with 0.45% normal saline (D5/1/2 NS). LPN/UM #1 stated they were for a resident who had been discharged and she was unsure how long the solutions were good for once removed from the protective overwrap. During inspection of the medication room refrigerator, an opened bottle of Tuberculin Purified protein derivative (PPD) 5 TU/0.1 ml (5 tuberculin units/0.1 milliliter) labeled house stock was dated opened 2/26/25. There was also an open bottle of Patient's own insulin aspart dated opened 1/18/25. When asked how long the bottles were good for once opened, LPN/UM #1 stated she believed the opened PPD and insulin should be discarded after 30 days. On 4/14/25 at 10:24 AM, the surveyor interviewed the Director of Nursing (DON), who stated the insulin bottle should have been discarded after 28 days, and the PPD solution should be discarded after 30 days. On 4/14/25 at 12:22 PM, the surveyor interviewed the Registered Nurse for Regional Staff Development (RN/RSD), who stated that IV bags that were resident specific must be used by the date printed on the pharmacy label, and any IV bag without a label and not in the overwrap must be discarded. The RN/RSD acknowledged the IV bags and the opened vials found by the surveyor should have been removed from active inventory. A review of the facility's undated Storage of Medications policy included . the facility shall not use discontinued, outdated, or deteriorated drugs or biological's. All such drugs shall be returned to the dispensing pharmacy or destroyed . NJAC 8:39-29.4(h)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) (designed to reduce transmission of multidrug-resistant organisms in nursing homes), to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of infection control practice. This was observed for 1 of 2 unsampled resident (Resident #39) reviewed for EBP. This deficient practice was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html On 4/9/25 at 10:59 AM, the surveyor observed a sign by the door of Resident #39 that the resident was on EBP, and a PPE bin was outside the room by the doorway. The sign had instructions for staff to wear gown and gloves during high-contact resident care activities that included dressing, hygiene, toileting, transferring, bathing/ showering, changing linens, device care, and wound care. The surveyor went inside the room to interview a sampled resident and noted the roommate, Resident #39 being changed. The surveyor asked Resident #39 if surveyor can observe them being changed which the resident agreed to. The surveyor observed Certified Nursing Assistant (CNA) #1 cleansed the body and changed the resident's incontinence brief. CNA #1 wore gloves but did not wear gown. When the resident was about to be turned to their side still unclothed but wearing incontinence brief, CNA #2 entered the room wearing gloves with no gown. CNA #2 assisted CNA #1 turn the resident to their side and finish putting on their clothing. A review of the Admission Record face sheet (an admission summary) revealed Resident #39 was admitted to the facility with diagnoses which included but were not limited to hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness of one side of the body following stroke) and neurogenic bladder (nerve damage causing lack of bladder control). A review of Resident #39's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 3/9/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS further revealed that the resident had an indwelling catheter. A review of the Order Summary Report (OSR) active as of 4/9/25 included the following physician's orders: - Enhanced barrier precautions related to catheter every shift. - Foley/ 16Fr for urinary retention, neurogenic bladder, and/or wound healing secondary to incontinence. - Foley catheter care every shift. A review of the comprehensive care plans revised on 12/13/24, included a focus for the resident being at risk for infection requiring enhanced barrier precautions for indwelling urinary catheter. The goal was for the resident to be free from signs and symptoms of active infection. The interventions included the following: Enhanced barrier precautions, use of gown and glove during high-contact activities such as dressing, hygiene, toileting, transferring, bathing/ showering, changing linens, device care, wound care, and therapy. On 4/9/25 at 11:40 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that staff had to wear gowns and gloves during high-contact activities when residents are on EBP to protect the residents with catheters from infection. The IP further stated that high-contact activities include incontinence care, dressing, showering, washing, transferring, and during feeding assistance in the resident's room. A review of the facility-provided policy titled Enhanced Barrier Precautions revised in March 2024, reflected under Policy Statement the following: To minimize the transmission of germs transferring from residents to staff hands and clothing, staff will wear gown and gloves when providing care to residents that require significant physical contact and are at high risk of acquiring or spreading Multidrug-Resistant Organisms (MDRO). NJAC 8:39 - 19.4 (a)(5)

Complaint #: NJ00179530 Based on interviews, review of the medical records, and other pertinent facility documents on 11/15/24, 11/18/2024, 11/21/2024, and 11/25/2024, it was determined that the facility failed to properly notify a Resident's (Resident #1) Primary Physician (RPP) of a need for increased supervision that was recommended by the Psychiatric Nurse Practitioner (PNP) on 11/6/2024. Resident #1 was on Q (Every) 15 minutes checks that was being done by the staff. The NP recommended 1:1 supervision for one week until the next evaluation because Resident #1 would not contract to safety during the meeting. On 11/9/2024, Resident #1 was found in adjoining in a bathroom standing up with a yellow plastic bag over their head and gripping strings tightly around their neck with their hands. The Resident was transferred to an Acute Care Hospital (ACH) for a crisis evaluation. This placed Resident #1 and all residents who are recommended for increased supervision at risk for harm, serious injury and or death for 1 of 5 residents reviewed. The Immediate Jeopardy (IJ) was identified on 11/21/2024 and the IJ template was provided to the facility on the same day at 4:45 pm. The IJ started on 11/6/2024 and continued until the facility sent a removal plan of action on 11/21/2024 with a completion date of 11/22/2024. The removal plan was reviewed and accepted on 11/22/2024. On 11/25/2024, the surveyors went onsite to validate that the removal plan was implemented. The facility implemented the removal plan, which included individual education for the involved Unit Manager, training for licensed nursing staff involved in receiving recommendations, notifications of changes in residents' status, and revision of physician notification policy. The noncompliance remained on 11/25/24 at a level G for actual harm that is not an IJ based on the facility staff have been educated on physician notification. The deficient practice was evidenced by the following: According to the admission record, Resident #1 was admitted to the facility with diagnoses which included but not limited to: Parkinson's Disease, Depression, and Alcohol Use. The Minimum Data Set (MDS), an assessment tool dated 10/29/24, indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the Resident's cognition was intact. The MDS revealed that the Resident scored 10 in section D (this section address mood distress and social isolation. Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home) D0160 (The Total Severity Score, does not diagnose a mood disorder or depression but provides a standard score which can be communicated to the resident's physician, other clinicians and mental health specialists for appropriate follow up) which indicated a total score of 10 (interpreted as moderate depression.) The MDS further revealed that Resident #1 was able to ambulate independently with or without an assistive device. A review of Order Summary Report, dated 10/29/24, revealed an order for Mirtazapine 7.5 mg, 1 tablet daily for Depression and Psychiatry/Psychology consult. A review of Resident #1's Baseline Care Plan, dated 11/3/24, revealed that the Resident to use plastic utensils, to be monitored every 15 minutes, and to remove all sharps and cords from the room. A review of Medication Administration Record, dated 11/2024, revealed on 1/3/24 at 12:49 p.m., Resident #1 was administered Xanax tablet 0.25 mg for anxiety. On 1/6/24 at 5:18 p.m., Resident #1 was administered Lorazepam tablet, 0.5 mg for Anxiety. A Review of Resident #1's progress notes (PN) revealed the following: On 11/3/2024 at 4:08 p.m., documented by Registered Nurse (RN #2), at 10:00 a.m. Resident #1's family member (FM) called who was upset and reported that the Resident was very anxious/depressed. pt states [she/he] worries about everything (i.e., clock stopped, eye dr. appt, finances, etc. [PMD was] aware, ordered [Xanax] 0.25mg bid [twice as needed,] observe for balance/gait and fall precautions. dose administered [at 12:45 p.m.] recheck pt appears calm [4:30 p.m. Resident #1] calls again stating .verbalized willingness to hurt [herself/himself] and has razors in the room. Room swept for dangerous items and removed. Initiated 15 min visual checks. [PMD] does not want crisis intervention, states .has always had episode of mania. Does not want to order [Urinalysis test] or labs to [to rule out Urinary Tract Infection]. Xanax [discontinued]. On assessment [Resident #1] denies any plan, states [she/he] agreed .nothing would happen tonight. [When] asked if it was to happen did he know what or think it thru, pt answered no. On 11/4/24 at 9:13 a.m., documented by UM/LPN #4, reached out to behavioral services at this time [related to] reports from weekend of pt having increased anxiousness and depression and statements about hurting himself .continues [every 15 minutes] as of this time. At 3:41 pm, documented by RN #4 .Mood appears anxious, sad, negative statements, tired/has little energy . At 10:05 p.m., documented by RN #1, .Mood appears anxious, tired/has little energy .currently on 1:1 care for suicidal ideations .talked about feelings and concerns. On 11/5/24 at 6:25 a.m., documented by LPN #5 .Mood appears anxious .talked about feeling and concerns. At 2:41 pm, documented by LPN#4 .Mood appears anxious, trouble concentrating . On 11/6/24 at 4:33 p.m., documented by UM/LPN #4, .recommendations received from the [PNP] are as follows following call .5. 1:1 supervision until face-to-face eval next visit .Spoke with [RPP] after speaking with [PNP] and [RPP] approved medication changes and new medication orders and gave orders to continue [every 15] minutes as of this time. [Resident #1] stated during telemed that if everything went well at [her/his] appointment on [Friday, 11/8/24, she/he] have a lot less anxiety and be able to 'relax.' Q15 minute checks to ensure [Resident #1's] safety continue as of this time. On 11/9/24 at 10:22 a.m., documented by the Supervisor/RN #2, resident found on floor in adjoining bathroom by another resident's family member with a yellow plastic bag over [her/his] head and gripping strings tightly around [her/his] neck. Visitor removed [her/his] hands and bag and notified staff. When asked what he was doing resident stated 'I'm trying to kill myself' .ems called for transport to ER for crisis evaluation . At 3:17 p.m., documented by LPN #3, nurse who was assigned to Resident #1 on 11/9/24 during 7:00 a.m. to 3:00 p.m. shift, the PN indicated Late entry for 0800 . At [9:40 a.m.] this writer was down another hallway when called by ancillary staff that resident was on floor, into bathroom of this resident to observe resident lying on floor and there was a visitor there also when the visitor stated my dad is in the next room and I wanted to check the bathroom and when i came in here I found this [woman/man] on the floor with a bag over [her/his] head and [her/his] hands around [her/his] neck .slurring [her/his] words when spoken to when this writer asked what happened resident stated, 'I want to Kill myself,' supervisor in room [ROOM NUMBER] activated, EMS, Paramedics arrived, and resident transported to local ER. Dr made aware and family notified. A Review of Resident #1's psychiatric notes dated 11/6/2024 from 2:00 p.m. to 3:00 p.m., revealed that Resident #1 had a video-conference with the PNP with the UM/LPN #4. The psychiatric notes indicated, . [Resident #1] made a comment to [FM] and staff feeling depressed about hurting [herself/himself]. [She/he] noted that [she/he] had razors as written. Harmful objects removed and [she/he] has been on every 15-minute checks. Patient seen with unit manager present. [She/he] appears quite anxious and hesitant to engage in formal until health assessment. Vaguely mentions a 'pickle' that [she/he] has gotten [herself/himself] into that [her/his] [wife/husband] does not know about. [She/he] is not agreeable to discuss in detail at this time. Admits [She/he] continues to feel hopeless and anxious. Significant depression. Reports sleep is variable. [She/he] openly admits that [she/he] is not able to contract for safety at this time but adamantly refuses inpatient psychiatric intervention. [She/he] denies any current suicide plan .The [Resident] reported feeling depressed, difficulty concentrating, no pleasures from life anymore, anxiety, insomnia, stress, and disturbing thoughts but no other psychiatric issues. The psychiatric notes indicated a plan included but not limited to: clinician suggested inpatient psychiatric hospitalization for severe depression, [she/he] declines at this time worried about [her/his husband/wife], I do not believe [she/he] meets criteria for commitment. Initiate suicide precautions, remove all dangerous objects from [her/his] room including cords, sharp objects and plastic trashcan liners, Styrofoam tray and plastic silverware only, 1:1 supervision until Face-to-face eval next week .Target behaviors include suicidal ideations, anxiousness, hopelessness, insomnia, ambivalence, apathy. Follow-up is needed . Review of RESIDENT MONITORING FORM from 11/6/24 to 11/9/24 indicated that the Resident was being monitored every 15 minutes. During a telephone interview with the surveyor on 11/19/24 at 11:43 AM, the PNP stated that on 11/6/24 during the video-conference call, Resident #1 did not promise to contract for safety prior to face-to-face visit on 11/12/24. The NP further stated that Resident #1 was a danger of hurting herself/himself and required 1:1 supervision. During a telephone interview with the surveyor on 11/19/24 at 12:20 PM, RPP stated that on 11/6/24 he received a call from UM/LPN #4 and notified him of the PNP's recommendations. However, the UM/LPN did not mention that the Resident did not contract for safety. According to the RPP he agreed with the LPN that 15 minute checks be done because the UM/LPN #1 reported that the Resident was doing fine on every 15-minute checks instead of the 1:1 supervision. The Physician further stated, If I had been made aware that the resident did not contract to safety during the video-conference with the Psychiatric NP, I would have agreed with the 1:1 supervision instead of continuing every 15-minute checks. During an interview with the surveyor on 11/21/24 at 10:24 AM, UM/LPN #2 stated that during the video-conference call on 11/6/2024, Resident #1 was very anxious about an upcoming eye appointment and had expressed some financial concerns but would not elaborate. LPN#2/UM stated that she was aware that Resident #1 did not contract for safety during the video conference call. LPN#2/UM stated that during the video conference call, Resident #1 stated that she/he would not hurt self if all went well with eye appointment. LPN#2/UM confirmed that she called the RPP and notified him of the PNP's recommendations. However, the LPN#2/UM failed to mention that Resident #1 did not contract for safety when she called the RPP to notify him of the NP's recommendations. The LPN #2/UM stated that Resident #1 should have been placed on 1:1 supervision as recommended by the PNP on 11/6/24 instead of continuing every 15-minute checks to prevent the incident on 11/9/24. During an interview with the surveyor on 11/21/24 at 11:00 AM with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), the DON stated that she was aware of the PNP's recommendations for Resident #1. The DON further stated that she felt that Resident #1 did not need 1:1 supervision because the resident did not have a suicidal plan. The DON stated that the incident that occurred on 11/9/2024 with Resident #1 was unavoidable and could have happened even if Resident #1 was on 1:1 supervision. However, the DON stated that she was aware that Resident #1 could not promise to hurt herself/himself if the eye consult did not go well. The LNHA stated, I may have considered the 1:1 supervision as recommended by the PNP if I would have read her notes and recommendations made on 11/6/24. A review of the facility's policy titled Physician Notification, dated 2/2024, indicated Policy: This outlines the guidelines for when and how healthcare should contact a resident's physician to inform them of significant changes in their condition, critical test results, or other situation requiring medical attention, ensuring timely intervention, and coordinated care. Procedure: 1. Clearly define situations that necessitate notifying the physician, such as .Unexpected complications Significant changes in patient status .3. Provide the essential information to communicate when contacting the physician, including .Current condition and recent changes Relevant medical history .Any immediate actions taken .Information relayed .When calling the doctor .2. Collect relevant details about the patient's status .any significant changes .4. Provide a concise and accurate summary of the resident's condition . NJAC 8:39-13.1(d) NJAC 8:39-27.1 (a)

Based on interviews and record review, the facility failed to provide mail delivery services on Saturdays for residents who resided in the facility. The deficient practice was identified for 5 of 5 residents, (Resident #12, #39, #41, #63, and #72) interviewed during the Resident Council Facility Task (a meeting with residents). The deficient practice was evidenced by the following: On 11/08/2023 at 10:33 AM, during the Resident Council Meeting, the surveyor interviewed Residents #12, #39, #41, #63, and #72 regarding mail delivery services. The five residents reported that the mail was not delivered on Saturdays. On 11/08/2023 at 12:45 PM, during an interview with the surveyor, the Director of Activities stated that residents' mail was delivered to the administrative building (building at a different location from the facility) where it got sorted. Then, an activity person picked up the mail and delivered it to the residents. During the same interview, the Activity Aide who was also present in the room, stated that letters were not delivered on Saturdays and Sundays because the administrative building was only opened from Monday through Friday. On 11/09/2023 at 11:34 AM, during an interview with the surveyor, the Administrator stated that residents' mail was delivered and sorted at another county building (the administrative building), and that they did not work on the weekends. A review of the facility policy titled, Opening Facility Mail, dated 10/14, did not address residents' mail delivery on Saturdays. N.J.A.C. 8:39-4.1(a)(19)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an accident/incident for 3 of 6 residents (Resident #22, #55, and #78) reviewed for accident/incidents. This deficient practice was evidenced by the following: 1.) On 11/03/23 at 10:23 AM, during the initial tour, the surveyor observed Resident #22 sitting in a wheelchair in their room. Resident #22 stated that he/she did not have any complaints about the facility. The surveyor reviewed the medical records for Resident #22. According to the Resident Face Sheet, Resident #22 was admitted with diagnoses that included dementia, high blood pressure, muscle weakness, and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body.) A review of the quarterly Minimum Data Set (MDS), an assessment tool utilized to facilitate care, dated 09/26/23, included the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated the resident's cognition was moderately impaired. A review of the Care Plan (CP), start date on 03/25/2022, included the resident was at risk for skin breakdown r/t [related to] decreased mobility, poor safety awareness with an approach to conduct a systematic skin inspection per protocol. A review of the Progress Notes (PN) from August 2023 revealed the following: -08/09/23 10:34, the Registered Nurse (RN) was called into the resident's room for assessment due to crying out in pain. The RN noted a negative x-ray result from right hip earlier in the week. The RN was unable to remove the resident's pants to assess, due to the resident's refusal. Pain medication was administered. The Certified Nursing Assistant (CNA) assisted the resident with activities of daily living (ADLs) and noticed a large bruise on the resident's right posterior leg. The RN was called back in the resident's room and noted right posterior knee area had a large bruise colored blue, purple, and yellow approximately 16 inches (in.) x 10 in. with a round hard edema (swelling) noted in entire bruised area. Resident #22 was sent out to the emergency room to rule out (r/o) right leg fracture or deep vein thrombosis (DVT - a blood clot that forms in a deep vein). - 08/09/23 18:46 (6:46pm), Resident #22 returned to the facility, included bruising to the right leg remains the same. -08/11/23 12:16, large hematoma (bruise) noted to lower extremity, excessive bruising noted. -08/13/23 06:33, bruising to back of right knee continues. -08/13/23 06:15, observed bruise at the right inner thigh down to joint. On 11/06/23 at 10:48 AM, the surveyor requested any accident and incident reports for Resident #22. On 11/08/23 at 10:07 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA), again, any accident and incident reports for Resident #22. On 11/08/23 at 10:51 AM, the surveyor observed Resident #22 in his/her room sitting in a wheelchair watching tv. Resident #22 stated that he/she did not remember having any bruises on their leg but that they were doing okay. Resident #22 stated that the care was good and that anything he/she needed that the staff assisted. On 11/08/23 at 11:05 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who stated that Resident #22 was on aspirin (ASA) 81mg daily. LPN #1 stated that skin assessments were documented on the paper chart on the resident's shower days which were twice a week. The surveyor asked LPN #1 what the process was if a resident obtained a bruise from an unknown origin and LPN #1 stated that for an unknown bruise they would have completed an incident report that went back for 72 hours. She further stated they obtained statements from the staff within the past 72 hours that cared for or had seen the resident. She then stated that the statements went to the Unit Manager (UM) which were then discussed during the morning meeting with the administrative team, and that the physician and the family were notified. LPN #1 reiterated the protocol for an unknown bruise included to write up an incident report to investigate on how it occurred. On 11/08/23 at 12:25 PM, the Director of Nursing (DON) stated that the incident report was completed but that she was still trying to find it. On 11/09/23 at 10:03 AM, the DON stated that she still had not found the incident report. At that time, the surveyor inquired about the bruise that was documented in the PN. The DON stated that she could not recall at that time about the bruise. On 11/09/23 at 10:29 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that if she observed a bruise on the resident or it was something new, she would inform the nurse. She stated that she would have had to write a statement on what she saw or what the resident was doing during the last time she saw the resident, and if it was witnessed or not. CNA #1 stated that once the statement was completed she gave it to the nurse. On 11/13/23 at 12:03 PM, the surveyor interviewed LPN #2 who stated that the skin assessments were in the medication administration record (MAR) and treatment administration record (TAR) which was signed on the shower days. LPN #2 stated that if there was something new then a progress note would have been written. The surveyor asked what the process for injuries of unknown origins such as bruises were and LPN #2 stated that if there was a bruise of an unknown origin then they would investigate and complete written statements that would go back three (3) days. She further stated that in the 3 day look back period, it included statements from whomever cared for the resident such as the aide, the nurses, as well as any staff member that may have seen the resident. LPN #2 stated that once the statements were completed that they were then given to the supervisor to be reviewed. LPN #2 stated it was important that a thorough investigation was completed so that the cause of the bruise would have been identified and then it would have been determined how to fix the problem based on what happened. LPN #2 stated that she cared for Resident #22 a few times but was not aware of any bruises back in August. On 11/13/23 at 12:13 PM, LPN #2 and the surveyor reviewed the PN in the electronic medical record (EMR) from 8/9/23 10:34, which reflected the bruising. She stated that an incident report should have been completed because we don't know what caused it and it looked unwitnessed. On 11/13/23 at 12:25 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she did recall the incident but did not know if there were statements. She stated that the statements should have been completed as the nurse normally completed them, but again reiterated, she was not sure if it was done since she could not find them. The ADON stated that a completed incident report was important because it ensured the resident was being taken care of and for the health and safety of the resident. She explained it was a communication tool for our staff to discuss what occurred and to brainstorm new interventions. The ADON stated that she knew the DON had looked to see if the incident reports were done but would look for the incident report and the 24-hour report related to the bruise. On 11/13/23 at 12:44 PM, in the presence of the survey team, the ADON confirmed that if the bruise was of an unknown origin, then an incident report should have been completed and that she would continue to look for the incident report. On 11/14/23 at 09:00 AM, in the presence of the survey team, the DON stated that an investigation was not completed and acknowledged it should have been done. She further stated that it was a learning experience and a good opportunity to educate the staff. On 11/14/23 at 01:05 PM, in the presence of the survey team, the DON stated the incident report should have been completed because it was important to know what happened and how an injury occurred. She further stated that after surveyor inquiry she educated the staff to ensure that an investigation was completed each time. On 11/15/23 at 10:12 AM, in the presence of the survey team, the ADON stated that during the assessment she looked at various reasons as to what may have caused the incident, which was the reason for completing an investigation. She further stated that Resident #22 tried to be independent as much as possible and liked to do things for themselves and would not always ask for help. The ADON stated that she asked if an incident reporting sheet was done but further stated that she did not follow up to see if it was completed. The ADON stated that it was protocol to investigate and get statements for any injury of unknown origin and it was my mistake that I did not follow up with making sure an incident report was completed. On 11/17/23 at 09:42 AM, in the presence of the survey team, the DON stated that it was important to investigate an injury of unknown origin to make sure abuse and neglect did not occur. She further stated that the only way to rule out abuse was to investigate it. The DON stated that it was important because it helped them track and care for the resident according to their needs. 33106 2.) According to Resident #55's Face Sheet, the resident was admitted to the facility with the diagnoses which included but were not limited to dementia, osteoporosis, and coronary artery bypass graft. A review of the quarterly MDS, dated [DATE], indicated that Resident #55 had severe cognitive impairment and required extensive to total assistance with activities of daily living (ADLs). On 11/08/23 at 11:29 AM, the surveyor observed Resident #55 sitting in a reclining chair with his/her legs hanging over the arm of the chair. The surveyor observed that the resident had multiple small skin tears and openings on the right lower extremity. The surveyor observed that one (1) skin tear on the right lower leg had a steri-strip (wound closure tape that keep wound edges together) intact. There was another small opening on the right upper leg near the knee that was undressed and a skin tear on the right bicep that was undressed. The surveyor observed that the resident had a band aide intact to the left elbow area. The resident was unable to be interviewed due to cognitive loss. The surveyor reviewed the Treatment Administration Record (TAR) for November 2023 and there were no treatment orders for the skin tear openings on the residents right lower extremity, left elbow, right upper leg near the knee and the right bicep area. The surveyor reviewed the physician order sheet dated 11/02/23 and there was a physician's order for a treatment order to the right upper bicep skin tear. The ordered indicated that the skin tear was to be cleansed with NSS (saline solution), gently pat dry, cover with border gauze, leave steri-strips in place until they fall off daily in14 days. The surveyor observed that the physician's order did not get transcribed onto the Treatment Administration Record (TAR) and there was no documentation that the treatment was being done. On 11/08/23 at 11:53 AM, the surveyor interviewed CNA #2 who stated that she had been employed in the facility for five (5) years. CNA #2 stated that Resident #55 required total care with all aspects of ADLs and was non-ambulatory (a person who is unable to walk). CNA #2 stated that the resident required two person assist for transfers and bed mobility. CNA #2 stated that the resident had skin tears on the left upper bicep area. She also added that the resident had scratches and opening on the right lower leg. On 11/08/23 at 01:03 PM, the surveyor, accompanied by the DON and ADON, all observed Resident # 55's skin. Resident #55 was in the dayroom sitting up in the reclining chair. The DON and ADON both confirmed that the resident had skin tears on the right lower leg, the right bicep, and the left elbow. They also confirmed that there were no treatments written in the TAR for any of these skin tears. The DON and ADON also both confirmed that there were no treatment orders for the right shin skin tear, left elbow skin tear and right upper leg. The ADON stated that this was not acceptable and that a full body assessment would be performed and that treatment orders would be obtained for the skin tears. The DON then explained that she received a verbal statement from the LPN, a full-time employee employed for many years, who identified that the resident had a skin tear on the right upper bicep on 11/02/23. The DON also stated that the LPN never initiated the incident/accident report and that the investigation into the cause of the skin tear on the right bicep was not conducted. The DON also confirmed that there was no documentation in the resident's medical record regarding the left elbow skin tear, the skin tear on the right upper leg nor the right bicep. The DON also confirmed that investigations into these skin tears were not conducted for the injuries of unknown origin. The DON explained that when the nurses performed skin checks on 11/01/23, 11/04/23 and 11/08/23 that the nurse did not put in any codes and there was no documentation of any new skin impairment. She admitted that the nurse may have been signing the TAR and not actually looking at the resident's skin. On 11/13/23 at 09:30 AM, the DON approached the surveyor and explained to the surveyor that the wound care practitioner came in to see Resident #55 on 11/08/23 and that treatments were ordered for all the resident's skin tears and that that all the wounds were documented on the resident's medical record. She also stated that investigations would be conducted related to the skin tears that were on the resident's right bicep, left elbow and right medial shin and that the Resident's Care Plan would be updated to include all interventions to prevent further reoccurrence of skin tears. The surveyor reviewed the wound care practitioner's consult, dated 11/13/23, which indicated that the wound care Nurse Practitioner (NP) identified that the resident had skin tears/laceration located on the right medial shin 1cm x 0.8 cm x 0.1 cm, right shin 0.5. x 0.4 x 0.1 cm, right bicep 2.4 cm x 0.3 cm x 0.1 cm and left elbow 0.9 cm x 1.2 cm x 0.1 cm. The NP documented that the resident had a skin tear related to thin, fragile, atrophic skin. Recommended preventing further skin injury by avoiding friction/shear, careful handling during ambulation assistance and transfer, using emollients, long sleeves, and pants when possible. On 11/14/23 at 11:20 AM, the DON explained the process for incident and accidents and conducting investigations. She stated that the incident/accident report was generated by the nurse that discovered the incident and an investigation would then have been conducted. She stated that the UM's responsibility was to review the report and ensure that treatments were in place. The UM was also responsible to review the preventative interventions, update the Care Plan with new interventions, and update the CNA Kardex with the new interventions. On 11/15/23 at 12:48 PM, the surveyor interviewed the Medical Director who stated that he was employed by the facility for 6 years. He stated that due to staff turnover and use of agency, it could complicate care and follow-through regarding resident care. 3.) A review of the resident Face Sheet (FS) indicated that Resident #78 was admitted to the facility with the diagnoses that included but was not limited to dysphasia (difficulty swallowing) and Alzheimer's disease. The admission MDS, dated [DATE], indicated that the resident had severe cognitive deficits and required extensive assistance with ADLs. On 11/03/23 at 10:55 AM, during tour of the [NAME] Unit, the surveyor observed Resident #78 sitting up in a reclining chair. The resident's eyes were closed, and he/she was not able to be interviewed due to severe cognitive deficits. A bandage was observed on the bridge of the resident's nose. CNA #3 was tending to the resident at this time and was interviewed. CNA #3 stated that the resident had fallen last week. The surveyor reviewed the residents' medical records which indicated the following: The Progress Note (PN) dated 11/03/2023 at 22:30 (10:30 PM) indicated that Resident #78 was found with a skin tear to the right forearm and posterior left shin. The PN also indicated that a treatment was ordered, and the physician and supervisor was made aware. The PN dated 11/04/2023 at 02:52 PM, a CNA identified that Resident #78 had a skin tear with some bleeding on the resident's left outer lower leg while the resident was in the recliner outside of the nurses' station. The skin tear measured 3.5 centimeters (cm) by 3 cm and a treatment was provided with NSS (saline) and steri strips (skin closure strips). A clean, dry dressing (CDD) was also applied. The PN indicated that the resident was agitated, anxious and restless in the recliner before the skin tear was found and may have bumped her leg against the recliner. The PN also indicated that the resident had leg sleeves that were on, but the left one was pulled up on the leg towards the thigh and was put back on her lower leg. The Treatment Administration Record (TAR) dated 11/03/23, reflected a physician's order to cleanse skin tear on the left forearm with NSS and apply triple antibiotic ointment and cover with a dry clean dressing twice a day for seven days. On 11/06/23 at 10:23 AM, the surveyor observed Resident #78 in a low bed with a mattress on the floor next to the bed. The resident was noted to be confused, had garbled speech, and was agitated. The resident had protective sleeves on the lower extremities. The surveyor observed that the resident had bruised knees and bruised fragile, thin skin on both upper arms. The surveyor also observed a dressing on the left forearm. CNA #3 entered the room at that time and was interviewed. CNA #3 stated that the resident had a skin tear on the left arm but did not wear protective sleeves on upper arms, just the lower legs. On 11/06/23 at 10:29 AM, the surveyor interviewed the LPN #3 who stated that she had been employed through the agency and had been coming to the facility for [AGE] years. The LPN described Resident #78 as anxious, restless, and required complete care ADLs. LPN #3 stated that the resident's medications were changed last week for the anxiety. She also explained that the resident was non-ambulatory and required 1 staff member to transfer. She stated that the resident utilized the wheelchair (w/c) or the reclining chair when he/she got out of bed. She stated that the resident was at risk for falls and that the preventative fall precautions in place which included: bed alarm, chair alarm, low bed, and a mattress on the floor next to her bed (crash pads). LPN #3 stated that the resident's skin was very fragile, and it did not take much for his/her skin to bruise or develop a skin tear. LPN #3 stated that the protective preventive measures to protect the resident's skin included protective sleeves on the resident's bilateral legs and moisturizer. LPN #3 stated that the resident did not wear any protective devices on his/her bilateral arms and did not have any response as to why there were no protective measures for Resident #78's fragile skin on the bilateral arms. The LPN stated that she was not sure if an incident or accident report was completed when the resident developed the skin tears on 11/03/23 and 11/04/23. The DON admitted that she was not aware that Resident #78 had developed skin tears on the left forearm and posterior left shin on 11/03/23 and on the left outer lower leg on 11/04/23. The DON explained that she did not think that any incident or accident reports were completed when Resident #78 developed the skin tears on 11/03/23 and 11/04/23. She stated that she would find out what happened and maybe the incident reports were on the unit. The DON indicated that it would have been important to ensure that preventive/protective measures were put in place to prevent the reoccurrence of skin tears on the resident's upper arms. She stated that protective or preventive measure should have been documented on the CNA Kardex and the Care Plan. The DON confirmed that the resident's CP and CNA Kardex were not updated with any new interventions to prevent the reoccurrence of skin tears on Resident #78's arms. On 11/13/23 at 12:36 PM, the DON provided the surveyor with incident reports for Resident #78's skin tears that were found on 11/03/23 and 11/04/23. She stated that the incident reports were sitting on the UM's desk and have not yet been investigated. She stated that the acting UM told her that she did not know what to do with the incident reports and that she was going to give them to the DON during the morning meeting but never did. The DON admitted that interventions were not implemented to protect the resident from further injury after the discovery of the skin tear on the left forearm and the back of the left shin on 11/03/23 and after the discovery of the skin tear on the left lower leg on 11/04/23. On 11/17/23 at 09:49 AM, in the presence of the survey team, the DON stated that she tried to investigate the skin tears after the fact and the information she had received was that the incident report did not make it to a supervisor or UM for review. She stated that there was an oversite related to a communication breakdown. A review of the facility's policy titled, Skin Report Worksheet, revised 04/2013, included, 2. The CNA Skin Report Worksheet is to be completed by the CNA at the time care is rendered and when that CNA observes a possible skin integrity concern. A review of the facility's policy titled, Skin Integrity Log: Impaired, revised 05/2015, included, To provide documentation and follow up of resident skin impairments such as bruises. 1. An Impaired Skin Integrity Log is to be initiated whenever new skin impairment is noted, other than a pressure sore. 7. Bruises will be assessed weekly for 2 weeks. A review of the facility's policy titled, Accident/Incident - Residents, Employees, Visitors and Agency Staff, revised 10/2021, included, 1. Reporting of Accident or Incidents: a. Regardless of how minor an accident or incident may be, it must be reported to the Department Supervisor, and the appropriate Accident/Incident Report form must be completed on the shift that the accident or incident occurred. 4. Investigative Action: a. The Nursing Supervisor or Department Supervisor must conduct an immediate investigation of the accident or incident and thoroughly complete the appropriate Incident/Accident Investigation Report. B. In completing any of the Accident/Injury Reports all witnesses and pertinent person(s) statement's must be obtained and attached. All completed Accident/Injury Reports, along with any documentations obtained, must be forwarded to the Director of Nurses Office as soon as possible. A review of the facility's policy titled, Investigating Unexplained Injuries, revised 09/2015, included, 1. Should a resident be observed with unexplained injuries (injuries of unknown source), the staff nurse must complete an Accident/Incident form and record such information into the resident's clinical record. 3. The Investigation will follow the protocols set for the facility's established investigational guidelines. On 11/15/23 at 12:32 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that he could not provide the facility's established investigational guidelines that were stipulated in the policy titled, Investigations of Unexplained Injuries. NJAC-8.39-4.1(a)5

Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to follow professional standards of practice for 2 of 19 residents (Resident #55 and # 195) by not a.) obtaining physicians' orders for treatments for (Resident #55 and #195), b.) providing treatments as ordered by a physician (Resident #55), c.) accurately assessing a resident's skin during weekly skin checks (Resident #55), d.) implementing interventions to protect a resident's skin identified as having frail, fragile skin (Resident #55) and e.) accurately assessing a resident's skin during a admission physical (Resident #195). This deficient practice was evidenced by the following: 1.) According to Resident #55's Face Sheet, the resident was admitted to the facility with the diagnoses which included but was not limited to dementia, osteoporosis (porous bones), and coronary artery bypass graft (CABG) is a procedure used to treat coronary artery disease. The quarterly Minimum Data Set (MDS) an assessment tool that facilitates care dated 10/02/23, indicated that Resident #55 had severe cognitive impairment and required extensive to total assistance with activities of daily living (ADLs). On 11/08/23 at 11:29 AM, the surveyor observed Resident #55 sitting in a reclining chair with his/her legs hanging over the arm of the chair. The surveyor observed that the resident had multiple small skin tears and openings on the right lower extremity. The surveyor observed that one (1) skin tear on the right lower leg had a steri-strip (wound closure tape that keep wound edges together) intact. There was another small opening on the right upper leg near the knee that was undressed and a skin tear on the right bicep that was undressed. The surveyor observed that the resident had a unsigned/undated band-aide intact to the left elbow and the area. The resident was unable to be interviewed due to cognitive loss. The surveyor did not observe any protective device in place to prevent the resident from developing any further skin tears. The surveyor reviewed the Treatment Administration Record (TAR) dated 11/1/23, and observed that there were no treatment orders for the skin tear openings on the residents right lower extremity, left elbow, upper leg near the knee or the right bicep area. The surveyor reviewed the physician order sheet dated 11/02/23 and there was a physician's order for a treatment order to the right upper bicep skin tear. The ordered indicated that the skin tear was to be cleansed with NSS (saline solution), gently pat dry, cover with border gauze, leave steri-strips in place until they fall off daily in14 days. The surveyor observed that the physician's order did not get transcribed onto the Treatment Administration Record (TAR) and there was no documentation that the treatment was being done. The surveyor reviewed the Progress Note (PN) dated 11/02/2023 at 07:18 AM, written by a Licensed Practical Nurse (LPN) that discovered the skin tear on the right upper arm. The progress note indicated that a treatment was applied to the wound, however the note did not contain a description of the wound or measurement of the wound. On 11/08/23 at 11:53 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that she had been employed in the facility for five (5) years. The CNA stated that Resident #55 required total care with all aspects of ADLs and was non-ambulatory (a person who is unable to walk). The CNA stated that the resident required two person assist for transfers and bed mobility. The CNA stated that the resident had skin tears on the left upper bicep area and there was a dressing on the area. She also added that the resident had scratches and opening on the right lower legs but did not wear any protective sleeves or devices on the legs or arms. On 11/08/23 at 12:00 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that she worked for an outside agency. LPN #1 stated that the resident had dementia and was non-verbal and requires total care and two persons assist with transfers and bed mobility. LPN #1 stated that the only treatment that the resident had was for skin protective skin creams and that the resident did not have skin tears and the resident's skin was intact. LPN #1stated that she did not receive any communication a in report about anything new happening with the resident. LPN #1 reviewed the Resident #55's TAR in the presence of the surveyor and confirmed that there were no treatment orders for the resident documented in the TAR. LPN #1 accompanied the surveyor to see the resident and confirmed that the resident had skin tears on the right lower extremity and the right bicep area. She stated that she would get the resident back to bed to examine the resident's skin. LPN #1 reviewed the physician order sheet with the surveyor and confirmed that the treatment order for Resident #55's bicep skin tear should have been transcribed onto the TAR to assure that the treatment was applied. The surveyor reviewed the TAR with LPN #1 who signed the TAR indicating she performed a body assessment for the resident on 11/8/23, however the resident had multiple skin tears. LPN #1 admitted that she signed the TAR that she performed a body assessment check but did not actually look at the resident's entire skin and did not identify that the resident had skin tears on the right upper bicep, right shin, left elbow and the right upper leg. On 11/08/23 at 12:14 PM, the surveyor interviewed LPN #2 who explained that when a nurse performed the weekly resident skin check, the nurse would document a code on the TAR. The codes were as followed: 1=no new skin injury, 2=previously noted skin injury, and 3=new skin injury see skin injury report. The surveyor observed that on the TAR there were only nurses' signature and no codes that indicated the skin was checked. LPN #2 reviewed the TAR with the surveyor and confirmed that the nurses who performed the skin checks for Resident #55 on 11/01/23, 11/03/23 and 11/08/23 failed to document the code and therefore you could not tell by looking at the documentation if the resident developed a new skin condition or not. On 11/08/23 at 12:25 PM, the surveyor interviewed the Director of Nursing (DON) who stated that if the nurse received a treatment order for Resident #55's skin tear of the right bicep, the nurse must assure that the order was transcribed to the TAR so that the treatment got performed. The DON also stated that when the nurse performed the skin assessments on 11/01/23, 11/03/23 and 11/08/23 the nurse should have documented that the resident had multiple skin tears on the right shin, left elbow and right bicep area. The DON did not have a response as to how the nurses did not observe these wounds during their assessments of the resident's skin. On 11/08/23 at 01:03 PM, the surveyor, accompanied by the DON and Assistant Director of Nursing (ADON) to observe Resident # 55 skin. The surveyor observed Resident #55 sitting up in the dayroom sitting in the reclining chair. The DON and ADON both confirmed that the resident had skin tears on the right lower leg, the right bicep, and the left elbow. They also confirmed that there were no treatments written in the TAR for any of these skin tears. The ADON and DON had both reviewed the physician orders and both confirmed that there was a treatment order written for the skin tear on the right bicep, however the treatment order was not transcribed to the TAR and therefore the treatment was never performed. The DON and ADON also both confirmed that there were no treatment orders for the right shin skin tear, right upper leg and left elbow skin tear. The ADON stated that this was not acceptable and that a full body assessment would be performed and that treatment orders will be obtained for the skin tears. The surveyor reviewed the progress notes (PN) dated 10/29/2023 at 21:17 (09:17PM) which indicated that the nurse observed 5 (five) small skin tears on the right shin area. The note reflected that the physician was notified, and the family was notified. The surveyor reviewed the physician' orders for October 29, 2023, and could not find a treatment order for the 5 skin tears that were located on the right lower shin area. The surveyor reviewed the PN dated 10/30/2023 at 07:55 AM, which reflected that Resident #55 would receive treatments to skin tears as ordered and would be given skin protectors sleeves for the bilateral shins and that the resident's recliner arms would be padded to prevent further skin tears. The surveyor observed the resident on 11/08/23, and the resident was not wearing protective skin sleeves on the bilateral lower legs and the surveyor did not observe that the resident's reclining chair arms were padded. The surveyor also reviewed the resident's medical records and there were no treatments ordered for the skin tears that were observed on the right shin. The surveyor reviewed a facility Incident and Accident report (IR) dated 10/29/23 at 20:00 (8:00 PM) which indicated that the resident was noted to have 5 small skin tears on the right shin. The IR indicated that the possible cause of the skin tears was that the resident swings his/her legs over the side of the recliner and there were metal sides to the reclining chair. The interventions were to pad the arms of the reclining chair. The surveyor did not observe the resident's reclining arms of the chair to be padded. The IR also indicated that protective leg sleeves would be applied to the residents' bilateral lower extremities, however the surveyor did not observe the resident wearing protective leg sleeves to the bilateral lower extremities. There also was not a physician's order for the protective leg sleeves to the lower legs and the resident's Care Plan did not reflect that these interventions were put in place to prevent further skin tears from occurring. On 11/09/23 at 09:40 AM, the surveyor interviewed the DON who confirmed that the preventive interventions that were to be put in place to protect the resident from further development of lower extremity skin tears were not implemented as indicated on the IR investigation dated 10/29/23 at 08:00 PM. The DON also confirmed that the nurse did not put verbal physician orders in for treatments to be performed to the right lower extremities skin tears, therefore treatment was not rendered from 11/01/223 until 11/08/23 after surveyor inquiry. The DON then explained that she received a verbal statement from the LPN a full-time employee employed for many years who identified that the resident had a skin tear on the right upper bicep on 11/02/23 and had written verbal treatment order for the skin tear however she forgot to transcribe the order to the TAR. The DON stated that as a result of not transcribing the order to the TAR, the treatment was never done to the skin tear on the right bicep from 11/03/23 until 11/08/23 after surveyor inquiry. The DON also stated that the LPN never initiated the incident/accident report and that the investigation into the cause of the skin tear was not conducted. The DON also confirmed that there was no documentation in the resident's medical record regarding the left elbow skin tear or right upper leg and that treatment orders were not obtained and no investigation was conducted for the injuries of unknown origin. The DON explained that when the nurses performed skin checks on 11/1/23, 11/4/23 and 11/8/23 the nurse did not put in any codes and there was no documentation of any new skin impairment. She admitted that the nurse may have been signing the TAR and not actually looking at the resident's skin. On 11/13/23 at 11:02 AM, the surveyor interviewed the Licensed Practical Nurse acting Unit Manager (LPN/UM #1) who documented the Progress Notes (PN) on 10/30/2023 at 07:55 AM, that she would obtain treatment orders for 5 small skin tears that were located on the right shin area. The acting LPN/UM #1 stated that she must have asked another nurse to obtain the treatment orders for the residents' right shin skin tears and the other nurse did not obtain the orders. She continued to explain that would have been important to assure that these treatments were done to prevent infection and to promote healing of the skin. The acting LPN/UM #1 continued to admit that she also failed to assure that the interventions such as skin sleeves or padding of the chair was done. She stated that the interventions would have been important to put in place at the time to prevent skin tears from reoccurring. On 11/13/23 at 09:30 AM, the DON approached the surveyor and explained to the surveyor that the wound care practitioner came in to see Resident #55 on 11/08/23 and that treatments were ordered for all the resident's skin tears and that that all the wounds were documented on the resident's medical record. She also stated that investigations will be conducted and that the Resident's Care Plan would be updated to include all interventions to prevent further reoccurrence of skin tears. The surveyor reviewed the wound care practitioners consult dated 11/13/23, which indicated that the wound care Nurse Practitioner (NP) identified that the resident had skin tears/laceration located on the right medial shin 1cm x 0.8 cm x 0.1 cm, right shin 0.5. x 0.4 x 0.1 cm, right bicep 2.4 cm x 0.3 cm x 0.1 cm and left elbow 0.9 cm x 1.2 cm x 0.1 cm. The NP documented that the resident had a skin tear related to thin, fragile, atrophic skin. Recommended preventing further skin injury by avoiding friction/shear, carful handling during ambulation assistance and transfer, using emollients, long sleeves, and pants when possible. On 11/14/23 at 11:20 AM, the DON explained the process for incident and accidents and conducting investigations. She stated that the incident/accident report was generated on the unit by the nurse that discovered the incident. The unit manager was then responsible to review the report and assured that treatments were in place. The Unit Manager was also responsible to review the preventative interventions, update the Care Plan with new interventions, and update the CNA Kardex with the new interventions. The DON stated that the CNA Kardex was the most easily accessed piece of information regarding resident care and the needed to be updated to assure that the CNA knew how to care for the resident. On 11/15/23 at 12:48 PM, the surveyor interviewed the Medical Director who stated that he was employed by the facility for 6 years. He stated that due to staff turnover and use of agency, it could complicate care and follow-through regarding resident care. On 11/16/23 at 11:03 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she could not provide a policy regarding the weekly skin checks that were done on shower days. The ADON also confirmed that when then skin tears were identified that a weekly skin log should have been implemented so that the wounds could be monitored weekly. She stated that this process was never implemented for Resident #55's skin tears. 48618 2. On 11/06/23 at 11:40 AM, the surveyor observed Resident #195 in the room sitting up in a recliner eating lunch. The resident told the surveyor that staff respond if anything was needed. At that time, the surveyor observed a 2x2 inch band-aid on the resident's upper right side of the resident's forehead. The band-aid was not signed or dated. The surveyor reviewed the hybrid medical record for Resident #195. According to the Admission Record (an Admission Summary), Resident #195 was admitted with diagnoses that included, but were not limited to, generalized weakness, anemia unspecified, and cellulitis (infection of the skin caused by bacteria) of buttock. A review of the resident's Minimum Data Set (MDS) dated [DATE], had a BIMS of 13/15 which indicated that the resident was cognitively intact. A review of the Admission Physical dated 10/22/23, indicated in the Skin Section: No rash or lesions, small sacral decubitus ulcer Stage II. The Admission Physical documentation further reflected that there was no identified concern with the resident's forehead. A review of progress note dated 10/20/23 at 15:56 (3:56 PM), indicated, [Resident #195] presents with sacral pressure related to using bedpan at home, scabbed lumplike area on top of head, bruising to bilateral arms, and moist scabbed area to right Achilles. A review of the Physician's Orders reflected an order dated 11/9/23, for the treatment of the scabbed area on the resident's forehead. This Physician's Order was implemented after surveyor inquiry. A review of the November 2023, Treatment Administration Record (TAR) reflected that the nurses were not signing for the care of the scabbed area on the resident's forehead from 11/1/23 - 11/8/23. A review of the Care Plan initiated 10/21/2023, included a focus area that the resident was at risk for impaired skin integrity related to anemia, decreased mobility electrolyte derangement and history of breakdown. Th care plan intervention included that any signs of skin breakdown (sore, tender, red, or broken areas) were to be reported. On 11/09/23 at 08:47 AM, the surveyor observed the resident lying in bed. The resident stated that staff changed his/her bandages every other day. The surveyor observed a 2x2 inch band-aid on the upper right side of the resident's forehead. The band-aid was not signed or dated. On 11/15/23 at 10:49 AM, the surveyor entered the resident's room accompanied by the LPN/UM #2. The resident was awake, lying in bed, and watching television. LPN/UM #2 asked the resident if it was okay to look under the band-aid on forehead and the resident stated it was fine. The surveyor noted that the band-aid was timed, initialed, and dated for that morning. LPN/UM #2 told the surveyor that the treatment nurse had changed it as ordered. LPN/UM #2 removed the band-aid from the resident in the presence of the surveyor. The surveyor observed a light amount of bright red blood, visible on the gauze of the band-aid and a barrier cream appeared to have been applied. The surveyor further observed the opened area as a raised lump with bright red blood at the tip. Upon resealing the band-aid the resident asked how it looked, and LPN/UM #2 stated that compared to what LPN/UM #2 remembered there was no longer a scab and the skin was healing, and they would continue to monitor. On 11/09/23 at 09:25 AM, the surveyor interviewed the LPN/UM #2, who stated that skin assessments were completed for each resident on shower days but also at each time of contact. The LPN/UM #2 said that any new observations or significant changes in current wounds could be reported by any staff member. Each concern should be documented, and the doctor would be notified so that treatment could be recommended if needed. The LPN/UM #2 explained that the facility contracts for wound care services. There was also a wound care nurse on staff in case there is an immediate concern. LPN/UM #2 said that if a new wound was identified, or a change in a current one was noted, the in-house doctor was notified as well as the contracted provider. If the concern was not immediate, the contracted provider would assess in-person on their next scheduled day at the facility. On 11/09/23 at 10:59 AM, surveyor interviewed LPN #3, who stated that they could not speak to wound care because those treatments were completed by treatment nurse and LPN #3 was the Medication Nurse for the unit. LPN #3 said that they are aware that Resident #195 had a pressure ulcer on the sacrum and on the right heel. LPN #3 said that any new skin issues were reported to the Unit Manager immediately and if new treatments were implemented, they would be followed. LPN #3 said that care plans were updated by the UM. When asked about the band-aid on the forehead of Resident #195, LPN #3 stated that the resident was admitted to the facility with a scabbed bump on the forehead and, at the request of Resident #195 and the family, the band-aid was placed as a deterrent to prevent the resident from picking at the scab. On 11/14/23 at 11:18 AM, the surveyor interviewed LPN #4 who said that he/she was assigned as the unit's treatment nurse and that treatments were completed as ordered. When asked about wound care, LPN #4 said that they had just completed the wound treatment on the forehead of Resident #195. On 11/14/23 at 12:05 PM, the surveyor interviewed the ADON who said that the resident was admitted to the facility with a scabbed lump and a band-aid had been placed per the request of the family to deter the resident from picking at the scab. ADON said that on 11/9/23 after the resident's shower, the family requested for the area to be assessed because the band-aid was falling off. ADON said that the doctor was contacted, and a treatment was ordered and implemented on 11/9/23. On 11/15/23 at 10:45 AM, the surveyor interviewed the LPN/UM #2 who said that Resident #195 was admitted to the facility with a scabbed bump and the original band-aid was placed as a preventative measure, per the resident and family's request because the resident would pick at it at home. The family expressed concern on 11/9/23 that the band-aid fell off after the shower and Resident #195 started picking at it again. LPN/UM #2 said that the doctor was contacted and a treatment was ordered. The surveyor asked how long the previous band-aid had been on for and LPN/UM #2 said it was changed daily but there was no documentation noting that. LPN/UM #2 stated that a treatment should have been ordered upon admission. LPN/UM #2 said that a request for a wound consult was emailed to the contracted provider. On 11/15/23 at 11:00 AM, the surveyor interviewed NP who was at the nurse's station. The NP said that they had been asked to assess the forehead of Resident #195 that morning. The NP further explained that a treatment was currently in place and that the NP was planning on seeing the resident next week because the resident had already been seen for that week and the concern was not reported as an emergency. The NP further stated that the Resident #195 was under their care, but NP had not been asked to assess the resident's forehead prior to that day (11/15/23). On 11/16/23 at 12:50 PM, the surveyor interviewed the DON who stated that the lump should have been noted on the Admission Physical by the doctor. The DON further stated to the surveyor that the area should have been assessed and a treatment should have been implemented by a physician. The DON explained that the resident's care plan should have been updated to reflect the resident's skin care. The facility policy titled, Skin Integrity Log: Impaired dated 05/15 indicated the purpose for the policy was to provide documentation and follow-up of resident skin impairments such as skin tears, abrasions, rashes, bruises, and other types of impaired skin integrity other than pressure ulcers. The policy indicated that weekly assessments of skin tears would continue until the area was resolved. The facilities policy titled, Wound and Skin Care Protocols dated 02/13 indicated that the purpose of the policy was to provide a systematic approach and monitoring process for skin integrity and chronic wound care. The policy purpose also indicated that the facility would maintain the resident's skin integrity and promote wound healing. The facility policy titled, Physician's Orders and dated 01/13 indicated the purpose of the policy was to communicate and document the physician's order for care and treatment of residents. The policy reflected that the licensed nurse would note all orders to indicate that the order has been carried through including notifying the pharmacy, transcribing the orders to the Medication Administration Record (MAR) and the TAR or other documentation as indicated. The policy further indicated that each chart would be reviewed during the twenty-four (24) hour chart check procedure by the night nurse. All orders written since the last chart check will be reviewed to ensure it has been noted and transcribed correctly. The facility policy, Kardex with a revised date of 01/15 indicated that the purpose of this tool is to communicate resident care information to all nursing, rehabilitation, restorative and interdisciplinary (IDT) team members. The policy also indicated that the Kardex would be changed, as Resident care needs change. NJAC 8:39-27.1

Based on interview and review of pertinent facility documentation, it was determined that the facility failed to: a.) provide in-service education at least once every 12 months for 2 out of 5 Certified Nursing Aides (CNA)s personnel files reviewed, (CNA#1 and CNA#4) and b.) complete annual performance reviews for 5 out of 5 CNA personnel files reviewed, (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5). This deficient practice was evidenced by the following: On 11/16/23 at 9:09 AM, the surveyor reviewed the five CNA personnel files which revealed the following: - CNA#1 in-service education was dated 02/10/22. CNA#1 did not receive a performance evaluation. - CNA#2 did not receive a performance evaluation. - CNA#3 did not receive a performance evaluation. - CNA#4 in-service education was dated 02/10/22. CNA#1 did not receive a performance evaluation. - CNA#5 did not receive a performance evaluation. On 11/16/23 at 09:20 AM, the surveyor interviewed the Director of Human Resources for the county who stated that she oversaw the Human Resource Department for the entire county which consisted of over 40 different departments and she was solely responsible for holding the employee files. The Director of Human Resources told the surveyor that the facility had always been responsible for providing in-service education for the staff working at the county facility as well as conducting annual performance evaluations for staff. On 11/16/23 at 10:31 AM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that the facility did not have a Staff Educator who was the previous staff member responsible for providing in-service education. The LPN/IP further stated that the Staff Educator had stopped working at the facility in April or May of 2023 and was also the person who was responsible for completing the performance evaluations for the CNAs. On 11/16/23 at 11:12 AM, the surveyor interviewed the facility's Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) who stated that the Staff Educator had stopped working at the facility in late spring of 2023 and since then herself, the Assistant Director of Nursing (ADON), and LPN/IP had been fulfilling that job responsibility at the facility. The DON explained that the Staff Educator was a flexible position, the former staff member was available to work all shifts and was responsible for completing the CNAs performance evaluations which were not done. On 11/16/23 at 11:16 AM, the surveyor interviewed the facility's LNHA in the presence of the DON who agreed with the DON that the previous Staff Educator was formally responsible for providing annual in-service education to all staff working at the facility and was also responsible for performing the performance evaluations. The LNHA stated that process changed due to the fact the county implemented a hiring freeze upon the facility. On 11/17/23 at 09:58 AM, the surveyor conducted a follow up interview with the DON who stated that she did not recall the name of CNA#1 and CNA#4 had not worked at the facility for more than a year, however they were county employees. The DON told the surveyor that the facility did not have a policy and procedure for annual in-service education or a policy and procedure for annual performance evaluations. NJAC 8:39-43.17(b)

Based on observations, interviews, and review of facility documentation it was determined that the facility failed to: a.) ensure that food items were labeled, dated, and stored properly, b.) ensure that ice machines were cleaned and in safe operating condition, and c.) ensure that equipment was cleaned and maintained to prevent foodborne illnesses. This deficient practice was evidenced by the following: On [DATE] at 9:56 AM, the surveyor met with the Food Service Director (FSD) to begin the kitchen tour. 1. One gallon opened container of lemon juice was on the shelf on the seasoning rack. The FSD stated that the container did not belong there and it should have been refrigerated. The FSD immediately disposed of the container. 2. On the Salad Dressing Rack, located next to seasoning rack across from 3 compartment sink in the main kitchen, the surveyor observed a 2.5 feet by 1.5 feet sheet pan that contained food particles and stains. Two knives, a cardboard box, and an unknown kitchen appliance were on top. The FSD stated, I am not sure why it is there, then removed the tray and all items from the area to be washed. The FSD said that the purpose of keeping clean and dirty areas separate was, You don't want any areas where bacteria could be growing mixed with clean items. 3. At the time of the observation, the surveyor asked the FSD if the area was a clean area and the FSD explained that it was where clean items were kept after they were dry. The surveyor observed a red cutting board, 3 feet by 2 feet, which contained a black substance streaked across both sides. The surveyor observed a yellow cutting board, 3 feet by 2 feet, that had a black substance streaked across one side. The surveyor also observed a blue cutting board, 3 feet by 2 feet which contained food particles throughout the cutting board. The FSD immediately removed the cutting boards and stated that all cutting boards should be clean and free of particles and substances to prevent the spread of bacteria. 4. No log was noted on the ice machine in the main kitchen. The surveyor asked the FSD if there was a log and the FSD said, no. The surveyor wiped a clean paper towel across the inside cover and a black substance adhered to the paper towel. The surveyor observed the FSD do the same, and she obtained the same results. The FSD stated that there should not be black substance on the ice machine to prevent the growth of bacteria. 5. The surveyor and the FSD entered the walk-in refrigerator in the main kitchen. The surveyor observed nine, 10-pound unknown meats sealed in plastic wrap with no identifying information. The surveyor asked the FSD what they were, and the FSD explained that they were roast beefs that had previously been cooked. The FSD further stated that the meat should have a label identifying what it is and when it was opened, so that others can be aware of how long the meat is good for. 6. The surveyor and the FSD entered the walk-in freezer in the main kitchen. The surveyor observed a tray of biscuits that were open to air and not labeled. The FSD stated that they had served beef stew last night and that it should have been wrapped and labeled after use. The FSD further stated that food needed to be covered, labeled, and dated. The FSD removed the item to be disposed of in the presence of the surveyor. 7. On the bread rack, the surveyor observed: - 4 bags of hoagie rolls dated [DATE]. - a loaf of sliced rye bread with no label and no expiration date. - a loaf of club wheat bread dated [DATE]. - a loaf of marble rye, no date, no label, with greenish brown patches. At the time of the observations, the FSD disposed of each item and stated that each item should have been dated and anything that had expired should have been disposed of. 8. One gallon of [NAME] Cooking Wine on a shelf with a Best Buy date of [DATE]. The bottle was open. The FSD disposed of the bottle. A review of the undated facility's, Dietary Orientation: Safe Food Handling,, revealed 1. Cutting boards in good condition . 3. Cleaned and sanitized in dish machine after each use . A review of the undated facility policy, Proper storage and labeling of food in the refrigerator, indicated within the policy statement that: All food is to be stored and labeled in a safe and sanitary manner. Procedures: Food is to be labeled with what is inside the container . and Food is to be labeled with the use by date . Open items stored in freezer will be dated for a 6 month use by date . NJAC 8:,d+[DATE].2(g)

Based on observation, interview, medical record review and review of other pertinent facility documentation it was determined that the facility failed to a.) provide a safe environment to prevent the potential spread of infection by not following standards of infection control procedures for 1 of 6 residents reviewed for infection control (Resident #82) from 10/24/23 until 11/06/23, and b.) follow appropriate infection control practices and perform hand hygiene as indicated during dining observation for 1 of 3 units (West Wing) observed. The deficient practice was evidenced by the following: 1.) The surveyor reviewed Resident #82's Face Sheet (FS) which indicated that the resident had the diagnoses which included but was not limited to dementia and aphasia (a disorder that affects how you communicate). The admission Minimum Data Set (MDS) an assessment tool that facilitates a resident's care, dated 08/07/2023, reflected that the resident had severe cognitive deficits and required limited to extensive assistance with activities of daily living (ADLs). On 11/03/23 at 12:06 PM, the surveyor observed the resident sitting up in the chair in his/her room. The resident's responsible party (RP) was present in the room and was interviewed at the time. The RP stated that the resident had a rash located on the groin area and was not sure what the rash was but was being treated with a cream that appeared to be helping. The RP stated that she had no complaints regarding the care the resident received and that she was very happy with the care. The surveyor observed an isolation cart (cart containing personal protective equipment (PPE) such as gloves, isolation gowns, gloves and face masks) located in the front of the resident's doorway, however the surveyor did not observe any signage on the resident's door to indicate that the resident was on isolation. The surveyor interviewed the RP who stated that the isolation cart was in front of the door because the resident had a rash on the groin area and that you had to wear a gown and gloves when you provided care to Resident #82. The surveyor reviewed the nursing Progress Notes (PN) that indicated that following information: The PN dated 10/24/2023 at 08:00 AM [Recorded as Late Entry on 10/24/2023 08:08] for 10/23/23, indicated that the Nurse Practitioner (NP) was told by the Resident's spouse that Resident #82 had spots on his/her upper inner thighs. The PN indicated that the resident was assessed by the NP and it had appeared that there were more red spots with raised hard centers and that some red spots seemed to have flattened out and appeared smooth. The PN also indicated that the spots had no drainage and that the resident stated that the areas were not itching, however there was some stinging or burning. A dermatology consult was ordered, and the resident was put on contact precautions (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient had handled). The PN dated 10/24/2023 at 22:29 (10:29 PM), indicated that the resident was seen by dermatology and the reddened area on the resident's groin were biopsied. The PN dated 10/30/2023 at 04:27 AM, indicated that the resident was on contact isolation. The PN dated 11/01/2023 22:33 (10:33 PM), indicated that the resident was on contact isolation. The PN dated 11/02/2023 at 14:57 (02:57 PM) indicated that Resident #82 was on contact isolation precautions related to red spots on the inner thigh and isolation precautions were maintained during the shift. The surveyor reviewed the Care Plan and there was no documentation that the resident was on contact isolation. The surveyor reviewed the Certified Nursing Assistant Kardex (provides an overview of each patient and what care that was to be provided) and there was no documentation the resident was on contact isolation. The surveyor reviewed the Physicians Orders (PO) and there was no PO that the resident was to be on contact isolation. On 11/06/23 at 11:57 AM, the surveyor interviewed the primary care Certified Nursing Assistant (CNA #1) who stated that he was assigned to provide care for Resident #82. CNA #1 explained to the surveyor that the resident required extensive assistance with activities of daily living (ADLs). The surveyor asked CNA #1 why there was an isolation cart placed outside Resident #82's doorway and the CNA stated that Resident #82 was not on contact isolation and that the isolation cart in front of the resident's room was for another resident that had COVID. He stated that the resident's RP came in daily to wash and dress the resident. CNA #1 added that he was not aware that the resident was on contact isolation for a rash on the inner thighs and was not aware that he was supposed to don (put on) PPE when caring for the resident. He also stated that there was no signage on the door that indicated that the resident was on contact isolation. He stated that he did not get report this morning because he was there early before every other staff member. On 11/06/23 at 11:58 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that it was written on the 24-hour report that Resident #82 was on contact isolation for red spots on the inner thighs. She stated that she was not sure what the rash was and that she had not looked at it yet and was going to do the treatment this afternoon. She stated that it was documented on the 24 report that the resident was on contact isolation. She stated that contact isolation consisted of wearing gloves, gown, and mask when in contact with the resident or when performing care. The surveyor questioned LPN #1 regarding why the CNA was not informed that the resident was on contact isolation and LPN #1 stated that this was her first day and that she did not give the CNA report this morning. LPN #1 then proceeded to ask CNA #1, in the presence of the surveyor, why he did not know that the resident was on contact isolation, and CNA #1 responded, Because nobody told me. On 11/06/23 at 12:16 PM, the surveyor interviewed a nurse who identified herself as the acting LPN Unit Manager (LPN/UM). The acting LPN/UM stated that if any resident had a contagious infection that the nurse would have had to obtain a PO for the resident to be on transmission-based precautions (TBP). She stated that she was not positive that you had to get a PO and would have to check with management. She continued to explain that that if a nurse found out that a resident had a contagious infection that the nurse would have been responsible to notify the physician and the resident's family. She explained that if a resident was on TPB then signs would have been posted on the door to see the nurse and isolation carts would have been placed in the front of the resident's room. She also added that all staff would have been notified regarding the resident condition and that the family would also have been notified. She confirmed that it would have been important for staff to know if the resident had a contagious infection and what PPE the staff were required to wear when they cared for or came in contact with the resident. She stated that it was important that the appropriate PPE was worn, hand hygiene was performed and that specific medical equipment was assigned to that resident to both contain, and prevent, the spread of infection. She stated that it would have been documented in the 24 hour report and also documented on the resident's CNA Kardex and Care plan. She stated that Resident #82 had a biopsy and that it was determined that it was dermatitis, however the resident was put on contact isolation just in case because they did not know what the rash was. The acting LPN/UM stated that CNA #1 should have known that the resident was on contact isolation so that he could have worn the appropriate PPE when in the resident's room or when caring for the resident. She also reviewed Resident #82's medical record with the surveyor and confirmed that there was not a PO for the resident to be on contact isolation and it was not documented on the Care Plan, the resident's CNA Kardex, nor on the Treatment Administration Record (TAR). She stated that the resident's Kardex was something that the CNAs utilized to find out what type of care a resident required. On 11/06/23 at 12:23 PM, the surveyor interviewed LPN #2 who stated that you would not have to obtain a PO to put a resident on isolation and that it was nursing judgment. On 11/06/23 12:34 PM, the surveyor interviewed the Infection Preventionist (IP) who stated that stated that a PO was required to put a resident on isolation or transmission-based precautions (TBP). She stated that the PO should have been obtained for whatever type of TBP the resident was to be on. She also explained that signage should have been posted on the resident's door to see nurse. She stated the sign posted on the door was a notification to visitors or staff that something was going on with the resident and that they should see the nurse to obtain additional information before entering the resident's room. She continued to explain that an isolation cart was placed outside the room with the appropriate PPE, and that it should have been documented on the 24- hour report (24-hour communication form for each shift) that the resident was put on isolation. She stated that she told the nurse last week to put Resident #82 on contact isolation for the groin rash because she was not sure what the rash was. She admitted that she did not follow-up to make sure that the staff obtained a physician's order for the isolation. She stated that it should also have been documented in the TAR, on the CNA Kardex, and on the CP that the resident was on contact isolation. The IP admitted that she did not follow-up with Resident #82 to assure that this was implemented and stated that it was hard for her to follow-up because the administration had her performing other duties instead of focusing on her role as the facility's IP. The IP stated that the importance of ensuring that staff adhered to the contact isolation policy was to prevent the spread of infection. The surveyor reviewed the PN dated 11/06/2023 at 13:51 (01:51 PM) that the biopsy results came back from the dermatologist office and the rash was not contagious. The note also reflected that the resident was removed from contact isolation. On 11/08/23 at 10:15 AM, the surveyor interviewed the Director of Nursing (DON) who stated that when the resident was put on TBP the nurse should have called the physician to obtain an order for the resident to be on TBP. She continued to explain that the nurse would also have been responsible to get an isolation set up outside the resident's room which contained isolation gowns, masks, gloves, facial shields (PPE), and that signage was supposed to be placed outside the resident's door. The signage indicated that the visitor should stop and come to the nurse's station to find out what type of PPE and isolation was required to visit that resident. The notification that the resident was on contact isolation was written on the 24-hour report and the nurse would communicate this information to the CNA. She continued to explain that the IP usually would notify administration by way of phone and email. She stated that this all should have been documented in the progress notes, resident Care Plan and CNA Kardex. The DON confirmed that all these infection control processes should have been implemented. The DON also stated that these processes were required to be put into place to prevent the potential spread of infection. On 11/14/23 at 11:20 AM, the surveyor interviewed the DON who stated that the CNA Kardex was the most easily accessed piece of information regarding resident care and that it needed to be updated to assure that the CNA knew how to care for the resident. She stated that it would have been important to document in the Kardex that the resident was on contact isolation so that the CNA knew. The DON stated that the facility did not have a policy regarding Care Planning. On 11/15/23 01:20 PM, the surveyor interviewed the IP and the Medical Director who stated that a physician's order was required to put a resident on isolation. 43307 2.) On 11/09/23 at 11:56 AM, the surveyor observed a Certified Nursing Assistant (CNA #2) with two lunch meal trays on a rolling bedside table (BST) in the [NAME] Wing hallway. CNA #2 entered room [ROOM NUMBER] and placed a meal tray on the resident's BST then returned to the hallway, gathered the second meal tray, and entered room [ROOM NUMBER]. CNA #2 placed the meal tray on the resident's BST, opened the carton of milk and poured the contents into a cup, opened a straw, and placed it into the cup, opened the lid from the ice cream, then removed the plastic food lid and placed it on the BST. CNA #2 then opened the potato chip bag, cut up the food with the fork and knife, opened two sugar packets and poured them into the coffee and mixed it with a spoon. She then moved the BST closer to the resident, collected the trash and placed it into the food lid and left the room with the lid which contained the empty milk container, straw paper, sugar wrappers and ice cream lid and placed them on the rolling BST in the hall. The resident was then observed using her fork to eat her lunch. CNA #2 then moved the rolling BST with the dirty lid, up the hallway to the food cart, where she placed the dirty lid containing the trash, on top of the cart. She moved the BST aside, took a lunch meal tray from the food cart and placed it on the rolling BST, touched the front of her surgical mask to adjust the mask on her nose, rolled the BST down the hallway while stopping to remove an additional BST from the hall and placed it into room [ROOM NUMBER], then stopped at room [ROOM NUMBER], an isolation room. CNA #2 stood at the doorway and removed a disposable isolation gown from the personal protective equipment (PPE) bin and unfolded it. A speech therapist approached and spoke with the CNA, at which time CNA #2 loosely rolled up the isolation gown and placed it on top of the PPE bin and walked up the hallway. CNA #2 touched the right side of her hair while she stopped to speak with another staff member in the hallway, then walked to another hall to retrieve a towel from the linen cart and walked back to room [ROOM NUMBER]. CNA #2 then donned (put on) the rolled-up gown from the top of the PPE bin, donned gloves, knocked and entered room [ROOM NUMBER]. CNA #2 reached down with her right hand and moved the blue mat that was on the floor, she then pulled the privacy curtain partially between the residents, placed the towel over the resident as a clothing protector, moved the resident's BST, adjusted the bed linens, pulled a chair near the resident, moved the resident's bed closer to the wall, removed the food lid, set up the meal tray then sat in the chair and fed the resident lunch. No hand hygiene (HH) was observed during the observation. During an interview at that time, CNA #2 stated that HH should have been performed between each resident and acknowledged she did not clean her hands correctly during the meal tray pass observation. The CNA stated it was important to make sure HH was completed correctly during tray pass so germs were not transferred. On 11/09/23 at 12:18 PM, the surveyor interviewed the assigned Licensed Practical Nurse (LPN #3) who stated that during meal tray pass, hand sanitizing should have been done between residents to prevent cross contamination and spreading of germs. On 11/09/23 at 12:22 PM, the surveyor interviewed LPN #2, who stated she was the Charge Nurse on the unit today, and informed her of CNA #2's meal tray pass observation. LPN #2 acknowledged that CNA #2 did not perform HH correctly and stated that there were several missed opportunities for the CNA to perform HH. LPN#2 stated that HH should have been performed between each resident and that it was important to perform HH correctly to prevent cross contamination. On 11/09/23 at 12:36 PM, the surveyor interviewed the LPN Unit Manager (LPN/UM) who stated that HH should have been performed any time before and after resident care. The surveyor informed the LPN/UM of CNA #2's meal pass observation, and she acknowledged that the CNA did not perform HH correctly. She further stated that it was important to perform HH correctly to prevent the spread of germs. On 11/09/23 at 12:49 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that HH should have been performed by staff: prior to touching meal trays, with any contact with food items, with any personal contact with residents, and performed between residents. The surveyor informed the ADON of CNA #2's meal pass observation. She acknowledged that the CNA did not perform HH correctly and stated that it was important to perform HH correctly to prevent infection. On 11/13/23 at 09:58 AM, the surveyor interviewed the Director of Nursing (DON) who stated that HH should have been performed before entering a resident's room, when handling food, and performed between residents. The surveyor informed the DON of CNA #2's meal pass observation from 11/09/23. She acknowledged that the CNA did not perform HH correctly and stated that it was important to perform HH correctly to prevent the transmission of infection. On 11/13/23 at 10:15 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that HH should have been performed before passing meal trays, after providing the resident with their tray and preparing their food and performed in between each resident. The surveyor informed the IP of CNA #2's meal pass observation from 11/09/23. The IP acknowledged that the CNA did not perform HH correctly and stated that HH was the important first step in breaking the chain of transmission to any pathogen. On 11/15/23 at 12:19 PM, the surveyors met with the Administration team and the team was informed of CNA #2's meal pass observation from 11/09/23. The surveyor requested from the LPN/UM, IP, ADON, DON and Licensed Nursing Home Administrator any hand hygiene inservices for CNA #2 prior to 11/09/23. No documentation was provided. The surveyor reviewed the facility policy titled, Isolation-Notices of Transmission-Based Precautions, dated August 2019, that indicated that notices will be used to alert personnel and visitors of TBP while protecting the privacy of the residents. The policy indicated that when TPB are implemented, the IP or designee determines the appropriate notification to be placed on the room entrance door and on the front of the resident's chart to that personnel and visitors are aware on the need for and type of precautions. The surveyor reviewed the facility policy titled, Isolation-Initiating Transmission-Based Precautions, dated August 2019, that indicated that if a resident was suspected of, or identified as, having a communicable infectious disease, the charge nurse or nursing supervisor notified the IP and resident's attending physician for evaluation of appropriate TBP. When TPB are implement, the IP clearly identifies the type of precautions, anticipated duration and the PPE that must be used. The policy also indicated that the physicians are involved in decisions related to infection control and residents under their care. The surveyor reviewed the facility policy titled, Physician's Orders, dated 01/13, that indicated the purpose of the policy was to communicate and document the physician's order for care and treatment of residents. The surveyor reviewed the facility policy titled, Kardex, with a revised date of 01/15, that indicated that the purpose of this tool is to communicate resident care information to all nursing, rehabilitation, restorative and interdisciplinary (IDT) team members. The policy also indicated that the Kardex would be changed, as Resident care needs change. The surveyor reviewed the facility policy titled, Hand Hygiene, reviewed 2/14, that indicated, Procedure: 1. Indications for hand washing and hand antisepsis: c. Before having direct contact with Residents. i. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the Resident. The surveyor reviewed the facility policy titled, Personal Protective Equipment-Contingency and Crisis Use of Facemasks, dated April 2020, that indicated, General Procedure for Donning and Doffing Masks. 1. D. After touching a facemask or before changing a face mask, perform hand hygiene. f. Handle a mask only by the elastic ear loops. g. Refrain from touching the mask while it is in use. 2.a. Front of mask is contaminated-DO NOT TOUCH. The surveyor reviewed the facility policy titled, Personal Protective Equipment-Using Face Masks, revised September 2010, that indicated, Miscellaneous. 8. Handle mask only by the strings (ties). 9. Never touch the mask while it is in use. NJAC 8:39-19.4 (a)(m)(n)

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to implement Care Plan interventions to reduce the risk for injury for a resident with a known history of skin tears. This deficient practice was identified for Resident #78, 1 of 3 residents reviewed for accidents, and was evidenced by the following: The resident's Face Sheet (FS) indicated that Resident #78 was admitted to the facility with diagnoses that included but were not limited to dysphasia (difficulty swallowing) and Alzheimer's disease. The admission Minimum Data Set (MDS) an assessment tool utilized to facilitate care, dated 08/30/23, indicated that the resident had severe cognitive deficits and required extensive assistance with activities of daily living (ADLs). On 11/03/23 at 10:55 AM, during tour of the [NAME] Unit, the surveyor observed Resident #78 sitting up in a reclining chair. The resident's eyes were closed, and he/she was not able to be interviewed due to severe cognitive deficits. A bandage was observed on the bridge of the resident's nose. The Certified Nursing Assistant (CNA) was tending to the resident at this time and was interviewed. The CNA stated that the resident had fallen last week. The surveyor reviewed the resident's medical records which indicated the following: The Progress Note (PN) dated 11/03/2023 at 22:30 (10:30 PM) indicated that Resident #78 was found with a skin tear to the right forearm and posterior left shin. The PN also indicated that a treatment was ordered, and the physician and supervisor were made aware. The PN dated 11/04/2023 at 02:52 PM, indicated that a CNA identified that Resident #78 had a skin tear with some bleeding on the resident's left outer lower leg while the resident was in the recliner outside of the nurse's station. The skin tear measured 3.5 centimeters (cm) by 3 cm and a treatment was provided with NSS (saline) and steri strips (skin closure strips). A clean, dry dressing (CDD) was also applied. The PN indicated that the resident was agitated, anxious and restless in the recliner before the skin tear was found and may have bumped his/her leg against the recliner. The PN also indicated that the resident had leg sleeves on, but the left one was pulled up on the leg towards the thigh and was put back on his/her lower leg. The Treatment Administration Record (TAR), dated 11/03/23, reflected a physician's order to cleanse skin tear on the left forearm with NSS and appy triple antibiotic ointment and cover with a dry clean dressing twice a day for seven days. Resident #78's CNA Kardex (gives a overview of each resident's care) indicated that the resident required moderate assistance of one (1) staff member for ambulation and moderate assistance of one (1) staff member for transfers. Resident #78's Care Plan (CP) did not reflect interventions regarding preventative/protective measures for Resident #78's fragile skin on the resident's bilateral arms. On 11/06/23 at 10:23 AM, the surveyor observed Resident #78 in a low bed with a mattress on the floor next to the bed. The resident was noted to be confused, had garbled speech, and was agitated. The resident had protective sleeves on the lower extremities. The surveyor observed that the resident had bruised knees and bruised fragile, thin skin on both upper arms. The surveyor also observed a dressing on the left forearm. The CNA entered the room and that time and was interviewed. The CNA stated indicated that the resident had a skin tear on the left arm but did not wear protective sleeves on upper arms, just lower legs. On 11/06/23 at 10:29 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she had been employed through the agency and had been coming to the facility for [AGE] years. The LPN described Resident #78 as anxious, restless, and required complete care with ADLs. The LPN stated that the resident's medications were changed last week for the anxiety. She also explained that the resident was non-ambulatory and required one (1) staff member to transfer. She stated that the resident utilized the wheelchair (w/c) or the reclining chair when he/she got out of bed. She stated that the resident was at risk for falls and that preventative fall precautions were in place which included: bed alarm, chair alarm, low bed, and a mattress on the floor next to her bed (crash pads). The LPN stated that the resident's skin was very fragile, and it did not take much for his/her skin to bruise or develop a skin tear. The LPN stated that the protective preventive measures to protect the resident's skin included protective sleeves on the resident's bilateral legs and moisturizer. The LPN stated that the resident did not wear any protective devices on his/her bilateral arms and did not have any response as to why there were no protective measures for Resident #78's fragile skin on the bilateral arms. The LPN stated that she was not sure if an incident or accident report was completed when the resident developed the skin tears on 11/03/23 and 11/04/23. On 11/08/23 at 10:27 AM, the surveyor interviewed the Director of Nursing (DON) who admitted that she was not aware that Resident #78 had developed skin tears on the left forearm and posterior left shin on 11/03/23 and on the resident's left outer lower leg on 11/04/23. The DON explained that she did not think that any incident or accident reports were completed when Resident #78 developed the skin tears on 11/03/23 and 11/04/23. She stated that she would find out what happened and that maybe the incident reports were on the unit. The DON indicated that it would have been important to ensure that preventive/protective measures were put in place to prevent the reoccurrence of skin tears on the resident's upper arms. She stated that protective or preventive measure should have been documented on the CNA Kardex and the CP. The DON confirmed that the resident's CP and CNA Kardex were not updated with any new interventions to prevent the reoccurrence of skin tears on Resident #78's arms. On 11/13/23 at 12:36 PM, the DON provided the surveyor with incident reports for Resident #78's skin tears that were found on 11/03/23 and 11/04/23. She stated that the incident reports were sitting on the Units Manager's desk and have not yet been investigated. She stated that the acting Unit Manager told her that she did not know what to do with the incident reports and was going to give them to the DON during the morning meeting but never did. The DON admitted that interventions were not implemented to protect the resident from further injury after the discovery of the skin tear on the left forearm and the back of the left shin on 11/03/23, and after the discovery of the skin tear on the left lower leg on 11/04/23. On 11/17/23 at 09:49 AM, in the presence of the survey team, the DON stated that she tried to investigate the skin tears after the fact and that the information she had received was that the incident report did not make it to a supervisor or unit manager for review. She stated that there was oversite related to a communication breakdown. The DON also stated that there was not a policy regarding Care Plan or updating Care Plans. The surveyor reviewed the facility policy titled, Skin Report Worksheet, dated 04/2013, that indicated any preventative devices such as a wheelchair or geri-chair cushions, wedge cushions, boots, extra pillows, etc. will be ordered to relieve pressure to the area. The surveyor reviewed the facility policy titled, Kardex, with a revised date of 01/15, that indicated the purpose of this tool was to communicate resident care information to all nursing, rehabilitation, restorative and interdisciplinary (IDT) team members. The policy also indicated that the Kardex would be changed, as Resident care needs change. N.J.A.C 8:39-33.1 (d)

Complaint NJ #: 157448, 158079, 162538, 162579, 163502 Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 6 of 13 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Report completed by the facility for the week of 08/21/22 to 08/27/22 revealed the facility had no RN coverage for all shifts on 08/24/22 and 08/26/22. Review of the PBJ Staffing Data Report for Quarter 3 2023 (April 1 - June 30) revealed the facility had no RN hours for the following dates: -04/08/23 (Saturday) -04/09/23 (Sunday) -04/22/23 (Saturday) -05/21/23 (Sunday) -06/03/23 (Saturday) -06/07/23 (Sunday) Review of the Employee Daily Schedule By Shift, provided by the facility, for the aforementioned dates verified that there was no RN scheduled to work 8 consecutive hours on the following days: -08/24/22 -08/26/22 -04/08/23 -04/22/23 -05/21/23 -06/03/23 During an interview with the surveyor on 11/14/23 at 10:51 AM, the Staffing Coordinator stated there should be a RN in the facility daily for 8 consecutive hours. During an interview with the surveyor on 11/15/23 at 11:06 AM, the Director of Nursing (DON) stated there should be a RN in the facility for 8 consecutive hours daily. The DON further stated that there had been times when there is no RN for 8 consecutive hours when there are call outs. During an interview with the surveyor on 11/15/23 at 11:23 AM, the Licensed Nursing Home Administrator (LNHA) stated that there should be a RN in the facility daily for 8 consecutive hours. Review of the facility's Nursing Policy and Procedure Staffing Guidelines policy, revied 08/2022, included, The minimum staffing needed for each skill level (RN, LPN, CNA, and Unit Clerk) is determined by the nurse-patient ratio guidelines and the patient/resident care needs, i.e., level of acuity and based on New Jersey state minimum requirements. NJAC 8:39-25.2(h)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to properly label and date opened multidose medications for 2 of 3 medication carts (West Side 1 and East Side 1) inspected. This deficient practice was evidenced by the following: On 11/09/23 at 10:16 AM, the surveyor inspected the [NAME] Side 1 medication cart in the presence of Licensed Practical Nurse (LPN) #1. Inside the medication cart, the surveyor observed the following: -1 insulin lispro pen which was opened but not labeled with an opened date -1 insulin glargine pen which was opened but not labeled with an opened date At that time, the Assistant Director of Nursing (ADON) verified the insulin pens had been opened but not labeled with an open date. The ADON further stated that the pens should have been dated upon opening and that she would dispose of the insulin pens. On 11/09/23 at 10:30 AM, the surveyor inspected the East Side 1 medication cart in the presence of LPN #2. Inside the medication cart, the surveyor observed the following: -1 Breo Ellipta inhaler which was opened but not labeled with an opened date -1 Trelegy Ellipta inhaler which was opened but not labeled with an opened date At that time, LPN #2 stated the inhalers should have been dated upon opening. During an interview with the surveyor on 11/15/23 at 11:06 AM, the Director of Nursing (DON) stated insulin pens and inhalers should be dated upon opening. The DON explained that opened multidose medications should be labeled with an opened date so that the nurse knows how long the medication is good for based on manufacturer's guidelines. Review of the manufacturer's guidelines for Humalog (insulin lispro), revised 03/2013, included, In-use Humalog vials, cartridges, pens, and Humalog Kwikpen should be stored at room temperature . and must be used within 28 days or be discarded, even if they still contain Humalog. Review of the manufacturer's guidelines for Lantus (insulin glargine), revised 05/2019, included, Do not use Lantus after the expiration date stamped on the label or 28 days after you first use it. Review of the manufacturer's guidelines for Breo Ellipta, revised 05/2023, included, Discard Breo Ellipta 6 weeks after opening the foil tray or when the counter reads '0' (after all blisters have been used), whichever comes first. Review of the manufacturer's guidelines for Trelegy Ellipta, revised 06/2023, included, Discard Trelegy Ellipta 6 weeks after opening the foil tray or when the counter reads '0' (after all blisters have been used), whichever comes first. Review of the facility's Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles policy, dated 01/2020, included, Once any medication or biological package is opened, the Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. NJAC 8:39-29.4(h)

Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On [DATE], from 9:44 AM to 10:38 AM, the surveyor, accompanied by the Food Service Director (FSD) and Assistant Food Service Director (AFSD), observed the following in the kitchen area: 1. There was a wooden-handled knife in the knife holding box in the cook's area. When interviewed, the FSD stated, We don't have any wooden-handled knives that doesn't belong there because we don't use them. That must have been brought to the kitchen from another department. The FSD removed the knife from the kitchen. 2. There was a tray that contained single-serve portions of red Jello on a top shelf in walk-in refrigerator #4, dated ,[DATE]. When interviewed, the FSD stated, they expired yesterday, they shouldn't be there. The FSD threw the three Jellos in the trash. In addition, there was a box of puff pastry that was dated ,[DATE]. The FSD stated, Our policy is 72 hours, we didn't use it, and we are throwing it away. The AFSD threw the pastry in the trash. 3. The surveyor observed a maintenance worker servicing the ice machine in the kitchen. The maintenance worker was not wearing a hairnet. The FSD instructed the maintenance worker to don a hair net and stated, he knows better than that. 4. There was a box of frozen Simply Potatoes on a shelf in the Produce Refrigerator/Miscellaneous Walk-In that had a manufacturer's use by date of [DATE]. The FSD stated, That's expired, I'm throwing it out. There were (2) five-pound plastic containers of sour cream that had a best if used by date of [DATE]. When interviewed, the FSD stated, Those are expired, yes sir, they are trash. The sour cream containers were thrown in the trash. 5. There were (2) cardboard boxes of Sara(NAME)Sponge cake in the walk-in freezer that had no dates and no manufacturer use-by dates. When asked how long the sponge cakes had been in the refrigerator, the FSD responded, We can't tell how long they have been here. They don't look like they have been in here too long, but I get your point. They should have been dated. 6. A cardboard box of Market Pro Foodservice film (plastic wrap) was opened and exposed on top of the prep table. The FSD stated, That should be closed to prevent contamination. The FSD closed the container after removing several layers of plastic wrap and threw the removed wrap in the trash. On [DATE], from 9:21 AM to 9:52 AM, the surveyor, accompanied by the FSD, observed the following in the main kitchen: 1. There was a brown, unidentifiable substance on the interior of the ice machine door/lid. The brown substance came off on the surveyor's finger when wiped. The Ice Machine Cleaning Schedule Monthly attached to the upper outside of the ice machine revealed that the ice machine was cleaned for monthly cleaning on [DATE]. When interviewed, the FSD stated, That should be cleaned daily as part of our daily cleaning schedule. The FSD took a clean, white cloth and wiped down the ice machine's interior lid, which removed the unidentified brown substance. When asked, the FSD was unable to provide a policy/procedure or cleaning schedule pertaining to the daily cleaning of the ice machine. The surveyor reviewed the facility policy titled Personnel Standards, revised ,[DATE]. The policy revealed the following under the Procedure section: 1. In addition to the Employee Personnel Policies, Dietary personnel will be required to follow additional sanitary standards as follows: a. Hair restraints must be work (sic) at all times while on duty. The surveyor reviewed the Crest Haven Nursing & Rehabilitation Center dietary department facility policy titled Proper Storage and labeling of Food in the Refrigerator dated ,[DATE]. The policy revealed the following under the procedure section: All food is to be stored and labeled in a safe and sanitary manner. In addition, the policy revealed, Food is to be dated with the use-by date. 3 days from opened or prepared i.e., prepared or opened on ,[DATE], so it would be dated for 3 days, which would be ,[DATE]. Do not put opened date on product. Only the use-by date. After that date, all food will be discarded. The policy also stated, Open items stored in the freezer will be dated for a 6-month use by date. The surveyor reviewed the facility policy/procedure titled Walk-In Box and Freezer Checklist for Cooks, undated. The policy/procedure revealed the following: Check expiration dates, Check to make sure all items have dates and are labeled, and All cooks should be checking daily even when it is not your assigned time. If you see a problem-fix it. The FSD/facility was unable to provide a policy/procedure pertaining to the use or non-use of wooden-handled knives. NJAC 8:,[DATE].2(g)

C#: NJ 2 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on [DATE] and [DATE], it was determined that the facility staff failed to initiate and administer Basic Life Support /Cardiopulmonary Resuscitation (CPR) timely and appropriately to 1 of 3 sampled residents (Resident #2) reviewed for CPR. The facility also failed to follow their own policy titled Code Blue-Medical Emergency, when on [DATE], Resident #2 was found unresponsive with no apical or carotid pulse at 4:40 p.m., in the resident's bathroom by the Registered Nurse (RN) Supervisor and the Certified Nursing Assistant (CNA #1). Instead of initiating CPR and calling a code blue at this time, the RN Supervisor left Resident #2 with CNA #1 and went to get help. The RN Supervisor walked down the hallway and went to the nurse's station, where she announced over the intercom for the Licensed Practical Nurse (LPN) to come to the nurses' station because there was an emergency. The RN Supervisor then encountered a second Certified Nursing Assistant (CNA #2) and the LPN. The RN Supervisor then told CNA #2 to take the crash cart to Resident #2's room and directed the LPN to perform CPR on Resident #2. The RN Supervisor proceeded to call 911, but could not get through to the number and contacted the Security desk to dial the number. The LPN and CNA #2 arrived at Resident #2's room with the crash cart at approximately 4:43 p.m., and the LPN initiated CPR. However; three minutes has passed since Resident #2 was found unresponsive at 4:40 p.m. The RN Supervisor returned to Resident #2's room at 4:45 p.m., but the RN Supervisor failed to announce a Code Blue response throughout the facility so that other licensed staff members could arrive to Resident #2's room and provide assistance. The Paramedics arrived at Resident # 2's side at 4:55 p.m. and found Resident #2 unconscious, unresponsive, and pulseless, and pronounced Resident #2 deceased at 4:57 p.m. This failure to administer CPR immediately and timely to Resident #2, who had documented resuscitation orders and an active Advanced Directive for resuscitation, resulted in an immediate jeopardy (IJ) situation and had the likelihood to affect all other residents in the facility who had an Advance Directive and resuscitation orders. The surveyor identified the IJ on [DATE] day 2 of the survey. The surveyor discussed the findings with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), on the same day at 2:25 p.m. The IJ ran from [DATE] through [DATE], when the facility began educating the RN Supervisor and all licensed staff on their policy and procedures. The Administrator presented an acceptable Removal Plan on [DATE] at 2:52 p.m., to the surveyor, which included the initiation of in-services for all licensed staff on the facility's policy and CPR administration. The facility had initiated the removal plan. A revisit was done on [DATE] to ensure the removal plan was implemented. This deficient practice was evidenced by the following: Review of the medical record (MR) were as follows: 1. According to the Face Sheet, Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Face Sheet also showed that Resident #2 was a Full Code. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of ,[DATE], which indicated the Resident was cognitively intact. The MDS documentation included that Resident #2 required staff assistance with all Activities of Daily Living (ADLs). According to the Facility Reportable Event (FRE) (a document used by facilities when reporting to the New Jersey Department of Health) dated [DATE], Resident # 2's neighbor (the Resident in the room next to Resident 2's room) reported to the Security Guard, that he/she heard a fall in the bathroom and Resident #2 calling for help. The Security Guard located the RN Supervisor and relayed the information to the RN Supervisor, who responded to Resident # 2's room with CNA #1. Also, the FRE revealed that Resident #2 was found lying face down in the bathroom, by the RN Supervisor and CNA #1. Further review of the FRE revealed that the RN Supervisor assessed Resident #2, who had no respirations, and no apical or carotid pulse. Also, after performing the assessment on Resident #2, which revealed the Resident had no respirations, and no apical and carotid pulse, the RN Supervisor left the room without initiating resuscitation for Resident #2, and CNA #1 remained with the Resident. The FRE also revealed that the RN Supervisor went to the nurses' station and called an LPN to start CPR on (Resident #2) while she called 911 On [DATE] the surveyor reviewed the Progress Notes (PN) dated [DATE] at 8:30 p.m., written by the RN Supervisor, which revealed that at approximately 4:40 p.m., the RN Supervisor was paged due to Resident #2 who had fallen in the bathroom. The PN revealed the RN Supervisor and CNA #1 found Resident #2 face down in the BR (bathroom), and the Resident face was purple and cold, and (he/she) was unresponsive Also, the PN revealed that CPR was started; 911 was called at 4:43 p.m. Resident # 2's PN also indicated that the AED (Automated External Defibrillator) was used, but no shock was recommended. Further review of the PN revealed the Paramedics arrived at 4:49 p.m., and there was no HR (heart rate) on their EKG reading, and (Resident # 2's) eyes were fixed and dilated. A review of a Care Plan (CP) revised [DATE], included Resident #2 was a full code, and has limited physical mobility, related to [MEDICAL CONDITION], a history of muscle weakness and a history of hip and knee surgery. A review of a Physician order [REDACTED].#2 had an Advanced Directives and was a Full Code. Review of an Advance Directives for Health Care (a legal document in which an individual indicates the actions that should be taken for their health if they are unable to decide for themselves) dated [DATE], for Resident #2 and signed by Resident # 2's power of attorney (POA), revealed if the Resident should suffer a [MEDICAL CONDITION] Resident #2 direct that CPR is provided to preserve the Resident's life. Review of the Resident Accident/ Incident Report (RA/IR) dated [DATE] and untimed, written by the RN Supervisor, showed Resident #2 had fallen while walking or standing. Under Summary and Conclusion, showed the Resident had a possible sudden death event. Under Corrective Action Plan revealed Inservice Nursing Staff- Code Blue/ Recitation/ CPR policy/ procedure The surveyor reviewed a facility's document titled Voluntary Statement Form (VSF), dated [DATE] at 6:38 p.m., written by the LPN. The LPN documented that the RN Supervisor paged overhead for her that we have an emergency, I need you. The LPN explained that she exited the restroom and observed CNA #2 with the crash cart. The LPN continued to explain that the RN Supervisor stated that Resident #2 was in the bathroom unresponsive. CNA #2 and the LPN ran down the hallway with the crash cart and entered the Resident's room. The LPN also documented that Resident #2 was observed lying on his/ her back next to the toilet. Resident #2 was unresponsive with no pulse, and I initiated CPR. The surveyor reviewed a second VSF, dated [DATE], at 9:00 p.m., written by the RN Supervisor. The RN Supervisor documented that the Security told her that Resident #2 fell in the bathroom. The RN Supervisor explained that she called CNA #1 to assist her with Resident #2, and when they walked into the bathroom, they found Resident #2 lying face down on the floor. Resident # 2's face was purple and cold, and the Resident was unresponsive. The RN Supervisor and CNA #1 log rolled Resident #2 onto her back for the RN Supervisor to assess the Resident. The RN Supervisor documented that Resident #2 had no carotid or apical pulse, and no respirations. The RN Supervisor further documented I called to the other LPN to start CPR while I called 911 . A review of the Paramedics report dated [DATE] at 11:34 a.m., and electronically signed by the Physician, revealed that on [DATE] at 4:47 p.m., the Paramedics were dispatch to the facility, due to [MEDICAL CONDITION] -Resuscitation in Progress. The report also revealed that the Paramedics arrived at Resident # 2's side at 4:55 p.m. and found Resident #2 unconscious, unresponsive, pulseless, apneic, asystolic, and (he/she) had lividity to the small of (his/her) back. Also, the report revealed that Resident # 2's pupils were dilated and not reactive. The Physician was notified, Resident #2 was pronounced deceased at 4:57 p.m. A review of the RN Supervisor employee file revealed that the RN Supervisor had current certification in CPR, with an expiration date of [DATE]. During a phone interview with the surveyor on [DATE] at 12:12 p.m., the LPN stated she was in the restroom and heard the RN Supervisor paging her overhead, I need your assistance. As she walked out of the restroom, she saw CNA #2 with the crash cart and the RN Supervisor, who then told the LPN that Resident #2 was unresponsive. The LPN stated that she and CNA #2 ran down the hallway towards Resident # 2's room and saw the Resident lying on her back without a pulse and was unresponsive. The LPN started doing chest compressions. The LPN further explained while doing chest compressions for Resident #2, the RN Supervisor called the room over the intercom system and asked the LPN if the RN Supervisor should come back to Resident 2's room. The LPN told the RN Supervisor that she should come back to Resident # 2's room. The LPN stated the RN Supervisor came back to Resident #2's room and took over chest compressions, and asked the LPN to get the Ambu bag off of the crash cart; the LPN gave the Ambu bag to the RN Supervisor. Then the RN Supervisor told her to go and make copies of the Resident's documents for the EMTs (Emergency Medical Technicians) responders. During an interview with the surveyor on [DATE] at 3:20 p.m., CNA #1 stated the RN Supervisor called her name and said to meet her in Resident # 2's room. The CNA stated that she went into Resident # 2's room with the RN Supervisor behind her. Resident #2 was in the bathroom face down, and she called Resident 2's name, but the Resident did not respond. CNA #1 explained that she told the RN Supervisor we have to turn Resident #2 over onto her back because the Resident's face was planted onto the ground, and Resident #2 was not going to be able to breathe. The RN Supervisor and CNA #1 then turn Resident #2 over, and they were still no response. CNA #1 also explained that the RN Supervisor checked Resident # 2's pulse and heart with a stethoscope, but the RN Supervisor did not do CPR, for Resident #2. During a phone interview on [DATE] at 9:20 a.m., the RN Supervisor stated herself and CNA #1 responded to Resident # 2's room and found Resident #2 face down in the bathroom, they both turned the Resident over onto his/her back, the Resident did not have a pulse and was not breathing. The RN Supervisor explained that she left CNA #1 in the bathroom with Resident #2 and ran to the nurses' station to call 911 and get help. The RN Supervisor indicated that she found the LPN, who was coming out of the bathroom, and asked the LPN to go to Resident # 2's room and initiate CPR. The RN Supervisor stated she did not call a Code Blue. When asked by the surveyor why she did not call a Code Blue or have a Code Blue called the RN Supervisor stated, I did not think of it. The RN Supervisor indicated she already knew that Resident #2 was a full code; therefore, she did not need to check the Resident's MR to verify his/her code status. The RN Supervisor also stated, I thought I could run to the phone and call 911 and come back. I thought it would be quick. Also, the RN Supervisor stated, I should have started CPR first and have (CNA #1) call 911 and call the other nurse. During an interview on [DATE] at 12:10 p.m., the DON stated the RN Supervisor is responsible for making decisions during a code. The DON also explained the RN Supervisor should have had CNA #1 called the code blue and get the LPN. The DON stated that the RN Supervisor left the room, called the code, and told the LPN to do CPR. The RN Supervisor should have stayed with Resident #2 and instituted CPR. The RN Supervisor did not follow the facility's policy. The surveyor requested to review the video camera recording for [DATE]. The video recording was reviewed on [DATE] at 10:26 a.m., in the presence of the ADON and security guard. The video recording showed the RN Supervisor entered the Security's office at 4:35 p.m. The RN Supervisor came out of the security guard's office at 4:36 p.m., went to the double door leading to the outside of the building, and returned with a pharmacy bag. At 4:38 p.m., the video recording showed The RN Supervisor walking towards the nurses' station. The video recording showed the RN Supervisor speaking with CNA #1 at 4:39 p.m., and they both walked down the hallway towards Resident # 2's room, with the RN Supervisor rolling an electronic blood pressure machine. The recording also showed the RN Supervisor and CNA #1 entered Resident # 2's room at 4:40 p.m., with the CNA in the lead. Further review of the video recording showed the RN Supervisor came out of Resident # 2's room at 4:41 p.m. and walked towards the nurses' station. The RN Supervisor arrived at the nurses' station at 4:42 p.m., and CNA #2 walked towards the nurses' station and spoke with the RN Supervisor. The LPN was observed walking by the nurses' station talking with the RN Supervisor, who was also on the phone at that time. The LPN and CNA #2, who had the crash cart ran down the hallway towards Resident # 2's room. The LPN and CNA #2 entered Resident # 2's room at 4:43 p.m., with the LPN in the lead. A review of the facility's policy titled Code Blue- Medical Emergency, dated ,[DATE], included but was not limited to the following: Under Purpose: To ensure cardiopulmonary resuscitation is initiated on any resident without a pulse or respiration, and who does not have a Do Not Resuscitate order. Under #3. Determining Code Status a. If a resident is found to be: i. Anemic (not breathing) ii. Useless iii. Does not have other signs of clinical death such as: 1. Rigor mortis 2. Fixed pupils Under #7. Roles in a code: a. Team Leader: Supervisor or RN who is CPR certified will coordinate the sequence of the code and initiate code record. b. Airway Manager: Responsible for use of the Ambu-bag. c. External Chest Compressor: A staff member who is CPR certified. d. Recorder: RN or LPN. e. Runner a licensed staff member who is responsible for: i. Checking the Resident's chart for code status. ii. Notifying the receptionist or Security of the code. iii. Calling 911. The Immediate Jeopardy (IJ) to Resident #2's health and well-being began on [DATE] when Resident #2 was found pulseless and unresponsive and delayed, and incorrect CPR was administered and ended on [DATE] when the facility started in-servicing the RN Supervisor and its other licensed staff. The RN Supervisor did not follow the policy, as mentioned above. The Administrator presented a Removal Plan, which was accepted by the surveyor on [DATE] at 2:52 p.m. A revisit was done on [DATE] to ensure the removal plan was implemented as follows: Actions taken to the situation identified: 1. Corrective action was taken on [DATE], by inservicing the nurse involved and initiating training of the licensed nurses on implementing the ABC's (airway breathing circulation) during a Code Blue Response in Long Term Care. Prompt initiation of CPR and CPR procedures Crash cart review AED review Demonstration of AED application Demonstration of proper chest compression and hand placement Proper oxygen administration Airway management Responsibilities of Code Facilitator Post-Code Documentation 2. All licensed nurses will participate in required education at least quarterly. The facility will conduct a Code Blue Drill and education monthly. Outcome will be reviewed with the Quality Improvement Committee. The education will be updated and adapted as needed. N.J.A.C: 8:,[DATE].4(c) 1 N.J.A.C: 8:,[DATE].1(a)

C# NJ & NJ Based on interview and a review of facility documentation, it was determined that the facility failed to fully investigate incidences per their Abuse Prevention Policy for 2 of 3 sampled resident's (Resident #2 and #3). On 10/15/12, Resident #2 reported to a staff member that she had been assaulted, and on 1/22/13 the same resident's family member reported an allegation of staff to resident abuse to a facility staff member. Resident #3 had 6 documented incidences of Injuries of Unknown Origin. Neither of the allegations regarding Resident #2, and none of the incidences of Injuries of Unknown Origin sustained by Resident #3 were investigated fully according to the facility's policy. The Immediate Jeopardy began on 1/22/13, was identified by the surveyor and reported to the Assiatant Administrator (AA) on 1/31/13. The Immediate Jeopardy was corrected on 1/31/13, based on an acceptable plan of correction submitted by the facility on 1/31/13. This deficient practice was evidenced by: Interviews and record reviews were conducted on 1/31/13 unless otherwise noted. 1. According to an "Admission Record" (AR) dated 5/10/12, Resident #2 was admitted to the facility on [DATE]. A Minimum Data Set (MDS), an assessment tool, dated 1/14/13 stated that the resident had a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) section of the MDS, which meant the resident was alert and oriented. A physician's orders [REDACTED]. An "Interdisciplinary Plan of Care" (IPC), originally dated 12/01/11 contained a problem of "Unpredictable behavior, verbally abusive, resistant to care, poor impulse control, poor safety awareness...history of verbalizing unsubstantiated complaints, accusations." The goal documented was that the "Number and intensity of episodes will decrease." Interventions to achieve the goal included but were not limited to: "Simple, direct communication...same caregiver as often as possible to establish a routine and rapport...1:1 as needed...approach calmly...be gentle but persistent." An update in the IPC dated 10/15/12 contained a problem of "[MEDICAL CONDITION]." An update in the IPC dated 1/22/13 contained a problem of maladaptive coping, manipulative behavior (with) family." An intervention dated 1/22/13 was "2 person assist (with) care, if resistant seek nurse." The surveyor reviewed the Interdisciplinary Progress Notes (IPN) for Resident #2, which were dated 1/20/13 and timed at 22:40 (10:40 pm). According to the entry, a staff member noticed a box of [MEDICATION NAME] in the resident's room and got the RN (Registered Nurse) supervisor "to go in the room with this nurse to ask resident to give us the box as she has no order for [MEDICATION NAME]." The entry further stated that the resident became angry, "got the box, took some pills out and threw them at this nurse (and) RN supervisor, but held some in her hand." According to the entry, the resident stated to the staff members "I'm not giving them to you." When the nurse and RN supervisor attempted to pick up the pills from the floor, "the resident attempted to hit this nurse (and) scratched this nurse's left arm." The resident also attempted to hit one of the staff members with her shoe. A third staff member, the other "med nurse" came in to assist. The writer of the entry left the room and the resident gave the rest of the pills to the med nurse. An entry made by the (AA), in the IPN dated 1/22/13, stated that the AA spoke with the resident's grandson regarding the incident on 1/20/13. The AA documented that the resident's grandson understood that the resident could not have medications at the bedside. The decision was made that the facility would provide 2 staff members to provide care due to the resident's "history/pattern of resistance to care and physical aggression." There was no documentation in the IPN written by the AA of an abuse allegation or investigation. The surveyor reviewed the facility's investigation regarding the abuse allegation which contained "Statement Information" from 3 staff members. The AA documented that she spoke with the resident's grandson who "was very upset" and felt that the staff "manhandled her (the resident)." The AA, Social Worker (SW) and RN Unit Coordinator discussed the issue with the resident's family via a telephone call. According to the documentation, the resident's grandson apologized for thinking that the staff was rough with the resident after she read to him the documentation in the nurse's notes regarding the issue. The AA further documented that the resident was interviewed and "did not comment about the staff being rough with her," but repeatedly stated that she wanted to return home. The AA further documented that she observed a "small discolored area" on the resident's right arm which, according to the resident was from her watch. The facility found that "there was no evidence of mistreatment based on the fact that the charge nurse (nurse's name) and (nurse's name), the RN supervisor were in the room together. The documentation was detailed and thorough. The resident had a history and pattern of obtaining OTC (over the counter) meds (medications)...has history of unsubstantiated complaints and will say anything to expedite her d/c (discharge) home." The care plan was updated. The remaining statements obtained from staff members were from the Director of Nursing and the RN who assessed the resident 2 days after the incident was to have occurred. The DON documented on 1/26/13 that an assessment was performed at 2pm "to the resident's upper and lower extremities - no discoloration noted - no indications of soft tissue injuries or skeletal alterations." A statement written on 1/28/13 by the RN who assessed the resident on 1/22/13 stated that "there was no bruising found on any of the locations specified by resident. The only discolorations noted were above her right wrist from what resident herself said came from her watch." The AA stated during an interview with the surveyor at 2:05 pm that the IPN written by the Licensed Practical Nurse (LPN), who was present at the time of the incident on 1/20/13, was taken as her written statement and that she "didn't feel the need to get others." The facility supplied the staffing for the 3-11 shift on 1/20/13. According to the schedule, there were 5 other staff members who worked on the unit during the incident. The facility did not obtain written statements from them, nor from the supervisor who was present during the incident. The surveyor conducted an interview with Resident # 2 at 10:50 am. According to the resident, she "had a fight" when a staff member found a box of [MEDICATION NAME] in her drawer. The resident then stated that she was holding the box of medicine and she "didn't want to give it up," and that "the nurse pulled my arms and she took it away from me." The resident further stated that she reported the incident to a nurse the next morning. The Social Worker (SW) stated, during an interview with the surveyor at 2:45 pm, that the resident's grandson called her two days after the incident occurred, and told her that the resident's arm was twisted and scratched by a staff member. The SW asked a Registered Nurse (RN) to "go see what happened." The SW stated that the RN called her and told her that she found no bruising on the resident. The SW further stated that she, along with the AA and the Unit Manager (UM) spoke with the resident's grandson and spouse via telephone regarding the incident. The surveyor conducted an interview at 2:10 pm with the RN who worked on the resident's unit on the day shift, following the alleged incident. The RN stated that on the day following the alleged incident (1/21/13), the resident did not report anything to her. According to the RN, the following day (1/22/13), the SW asked her to investigate an incident which had been reported to her regarding Resident #2. The RN spoke with the resident and stated that the resident "told me that a nurse came in and took her [MEDICATION NAME] and grabbed her. She told me it happened in the evening on Sunday." The resident described the staff member to me and showed the RN how the nurse grabbed her. "I saw no marks or indentations." The RN stated that "she told me that the marks on her wrist were from her watch." The RN further stated that she called the SW to tell her that she "didn't find anything out of the ordinary." A written summary of the event, dated 1/28/12 (13), stated that there were 2 nurses who were involved and that "both employees files were reviewed and neither have any reprimands or counseling in their files." The surveyor reviewed the employee files of the 2 nurses involved. There was no documentation in their files that the employees attended Abuse Prevention in-services. According to the AA during an interview with the surveyor at 5:15 pm, the staff member's inservice records were unavailable because the records were in a locked area and the staff member with access to the education files was not present. According to the facility's Abuse Prevention Policy (APP), the facility did not complete a full investigation into the allegation. Further, there was no indication that the staff members involved were suspended or monitored in any way pending the outcome of the investigation, which caused the resident's to be placed in jeopardy until the investigation was completed. 2. The ICP for Resident #2 also contained a problem of "Unsubstantiated c/o (complaint of) rape," dated 10/15/12. There was no goal entered on the ICP for the problem. Interventions to manage the problem included but were not limited to: "Investigation of allegation, provide resident opportunity to verbalize fears...no male Certified Nursing Assistants (CNA's)" The surveyor reviewed the IPN for Resident #2, dated 10/15/12 at 5:30 am. According to the entry, Resident #2 stated to a staff member "I was just rapped (sic)." The staff member then informed the resident that she (the resident), was "just asleep and there are no men working at this time." The resident then gave a general description of the person who she alleged had assaulted her. An ICP entry dated 10/15/12 at 11:30 am stated that the resident's story "remains consistent" as she spoke with another staff member about the alleged assault. According to the ICP, the resident stated that a "young tall, white skinny man with short cropped hair raped her in her room this morning just before her blood was drawn. Her story remains consistent. Continues to state that her (sic) covered her mouth and got on top of me." The resident further told the staff member that "maybe I dreamed it but it felt real." The resident allowed an "assessment of her perineal area...". No evidence of trauma, drainage, redness or discoloration was found. The documentation stated that "The resident watches TV all night long and perhaps dreamed it or heard something on the TV". The IPN further stated that the "team reviewed the information ([DIAGNOSES REDACTED]. The staff will continue current interventions and assist her in making more suitable TV viewing choices." The Department of Health (DOH) received a "Reportable Event Record/Report" (AAS-45) from the facility on 10/19/12, regarding the resident's allegation which was reported on 10/15/12. According to the AAS-45, a staff member woke the resident up at 5:30 am on 10/15/12 and the resident stated "I was just raped." According to the AAS-45, "the incident was reported and investigated." "The resident was not sent to the hospital because on 10/15/12 she admitted that she may have dreamed it and there was no physical evidence supporting the allegation." The document further stated: "Based on the lack of evidence, her history of unsubstantiated (sic) complaints, and the fact that the res. (resident) admitted that she dreamed it, the team did not feel it was a reportable event." The AAS-45 stated that "on 10/18/12 she again mentioned the rape." At that time, the facility notified the DOH, Office of the Ombudsman and the local police department. The statements that were taken included one from a Certified Nurses Aide (CNA) (dated 10/18/12), a RN (dated 10/18/12), and a LPN, (dated 10/18/12). The above statements were not those of any staff members that were working on the resident's unit when the incident was to have occurred. The statements which were obtained were as follows: A CNA documented in a statement dated 10/18/12 that the resident told her that she was "raped the other night, by a white man, and that she wanted the police called." The resident also told the CNA that she was upset that "nothing was being done about this and she doesn't feel safe at night." The CNA reported the conversation to an RN. A second statement dated 10/18/12, which was written by the Charge Nurse (CN) on the 3-11 shift, stated that the resident said "I was raped the other night." The CN reported the conversation to the supervisor. A LPN wrote a statement dated 10/18/12 which also stated that the resident stated that she was raped "a few nights ago." She said it was not an employee (and gave the LPN a male first name only) and said that it was "that tall man with the glasses who goes around into other peoples rooms." The LPN also documented that the resident said "Why is that man still here after what he did to me?" The staffing schedule was provided by the facility for the 11-7 shift on 10/14/12 into 10/15/12. According to the schedule 5 staff members and one supervisor were scheduled on that night. The statements obtained by the facility did not include any of those staff members. The facility was unable to supply statements from the staff of the 11-7 shift who worked on the shift that the resident alleged the incident occurred. The facility was unable to provide documentation that a complete investigation, which was reported to have been conducted by the facility when reported to the DOH, was conducted per their APP. 3. According to an Admission Record, Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A POF dated 1/2013 contained physician's orders [REDACTED]. According to an MDS dated [DATE], Resident #3 had a BIMS score of 2, long and short term memory problems and severely impaired cognition for decision making, and required assistance with all Activities of Daily Living (ADL's). The resident had no skin issues. An ICP originally dated on 1/31/11 contained a problem of "At risk for skin breakdown secondary to decreased bed mobility and incontinence. A second IPC dated 12/24/12 contained a problem of "L (left) chest discoloration. Interventions to manage the problem included but were not limited to: "monitor skin integrity q (every) shift and report/document changes in skin integrity." According to an IPN dated 5/28/12, Resident #3 had sustained a bruise on the left knuckle and was unable to tell the staff how the bruise occurred. The facility found that the injury may have occurred during mealtime when the table was over her lap. No abuse or neglect was suspected. A Resident Accident/Incident Report (RAIR) dated 5/26/12 was reviewed regarding the incident. According to the document, a CNA reported finding a bruise on the resident's left index finger at the knuckle. The resident's physician and family member were notified. The facility was unable to provide documentation of a complete investigation (with staff interviews/statements) into the cause of the bruise per their APP. An IPN dated 8/12/12 contained an entry which stated that a staff member "noticed blood dry in inside corner of R (right) eye." The surveyor reviewed a RAIR dated 8/12/12 regarding the observation made which stated that the causative factor of the incident was "unknown/unobserved." The RAIR further stated that the "Resident has a 0.2 centimeter (cm) scratch noted on outside corner of R eye. Scant dried blood noted with discoloration noted around scratch. Fingernails clean and trim." The incident was reported to the resident's physician and family member. The facility was unable to provide documentation of a complete investigation (with staff interviews/statements) into the cause of the injury per their APP. An IPN dated 8/19/12 at 6:45 am stated that the resident had a "discoloration to L leg also R foot (with) discoloration to top of foot toes." An IPN entry dated 8/19/12 at 9:30 am stated that the resident "may have banged her leg on bedside table during meal or on side of arm rest of recliner. No abuse or neglect suspected." The surveyor reviewed a RAIR dated 8/18/12 regarding the discoloration which stated that the causative factor of the incident was "unknown/unobserved," and that the resident had a "golf ball sized area of discoloration of L lower leg below knee..." The resident's physician and family were notified. The facility was unable to provide documentation of a complete investigation (with staff interviews/statements) into the cause of the discoloration per their APP. An IPN dated 10/02/12 contained an entry which stated that Resident #3 was found to have a bruise on the left hand. The entry further stated that the resident had been prescribed blood thinning agents and bruised easily. The surveyor reviewed the RAIR dated 10/02/12 concerning the bruise which stated that the causative factor of the incident was "unknown/unobserved." The RAIR further stated that the resident had profound dementia, was restless/active, and was unable to state how the incident occurred. The resident's physician and family were notified. The facility was unable to provide documentation of a complete investigation (with staff interviews/statements) into the cause of the bruise per their APP. An IPN dated 11/11/12 contained an entry which stated that the resident had a bruise on the L upper chest. The cause was unknown. The surveyor reviewed a "Resident Accident/Incident Report" (RAIR) dated 11/11/12 concerning the incident which stated that the causative factor of the incident was "unknown/unobserved." The RAIR further stated that a bruise was observed on the resident's L upper chest by a CNA "when she went in to do AM care." The resident was receiving [MEDICATION NAME] (a blood thinning agent) 75 mg daily. The resident's physician and family were notified. The facility was unable to provide documentation of a complete investigation (with staff interviews/statements) into the cause of the bruise per their APP. According to an IPN entry dated 11/13/12 at 8:45, Resident #3 was found to have an area of purple/yellow bruising above the L breast/L axilla area extending to the L upper arm. The area was painful to touch with swelling noted above the L breast/L axilla area. Bruising was first noted on 11/11/12 by a CNA. The resident's use of [MEDICATION NAME] 75 mg was thought to have contributed to the bruising. An untimed entry also dated 11/13/12 stated that the resident had an X-ray of the left shoulder and clavicle which showed no fracture or dislocation. An entry in the IPN dated 11/24/12 stated that a CNA reported to a nurse that the resident had bruising on the left chest and clavicle area which was first reported on 11/11/12, but that the L shoulder area/clavicle is swollen. Noted purple bruising to L axilla, swelling above L breast." According to the AA during an interview with the surveyor at 3:00 pm, the incidences on 11/13 and 11/24/12 were considered the same incident as the 11/11/12 bruise, therefore the facility did not generate a RAIR for the 11/13/12 and 11/24/12 changes to the bruised area. The facility could not provide documentation of a complete investigation (with staff interviews/statements) into the cause of the bruising per their APP. According to an IPN dated 1/14/13, timed at 11:00 am, Resident #3 was found to have a 0.5 cm by 0.5 cm discoloration on the left side of the nose and beneath the right eye. The "Resident may have reached toward her face and hit (with) fingernail. A RAIR dated 1/14/13 stated that the causative factor of the incident was "unknown/unobserved." The RAIR further stated that the discoloration was noted on the L side of the resident's nose beneath her L eye. The resident's physician and family were notified. The facility could not provide documentation of a complete investigation (with staff interviews/statements) into the cause of the discoloration per their APP. The surveyor reviewed the facility's "Abuse Prevention Policy." According to the facility's APP which was most recently revised in 12/12, "In-Service Training," Policy Interpretation and Implementation, "All employees are required to attend our facility's resident rights and abuse prevention program in-service training sessions prior to having any resident contact." Contained in the section "Reporting Abuse to Facility Management", #4: "When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility..." #11: A completed copy of the Resident Accident/Incident Report (if the incident led to an injury or potential for injury) and written statements from the initial investigation and witnesses, if any, must be provided to the administrator as soon as possible. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the administrator immediately upon completion." Contained in the "Abuse Investigation: section of the policy: #3: The individual conducting the investigation will, as a minimum: B. Review all events leading up to the alleged incident; F. Interview the staff members (on all shifts) who have provided direct care to the resident during the period of the alleged incident. #9: Employees of this facility who have been accused of resident abuse may be reassigned to a different unit or department or suspended from duty until the results of the investigation have been reviewed by the administrator. The same policy stated in the "Investigating Unexplained Injuries" policy statement: 2. "A listing of those individuals (i.e. caregivers, consultants, visitors, etc.,) who have had direct contact with the resident during the approximate time of the alleged incident will be compiled and provided to the person conducting the investigation. 3. The investigation will follow the protocols set forth in our facility's established abuse investigation guidelines." A prior version of the APP, (revised 5/06) stated in the "Policy Interpretation and Implementation" section that "The individual conducting the investigation will, as a minimum:...F. Interview the staff members (on all shifts) who have provided direct care to the resident during the period of the alleged incident..." The same policy contained within the section "Investigating Unexplained Injuries," that "An investigation of all unexplained injuries (including bruises, abrasions, and injuries of an unknown source) will be conduced by the director of nursing services, and/or other individual appointed by the administrator, to ensure that the safety of our residents has not been jeopardized." "2. A listing of those individuals (i.e. caregivers, consultants, visitors, etc.,) who have had direct contact with the resident during the approximate time of the alleged incident will be compiled and provided to the person conducting the investigation. 3. The investigation will follow the protocols set forth in our facility's established abuse investigation guidelines." The facility was cited for F226 on their Recertification Survey on 1/23/12, for failing to conduct a thorough investigation of an allegation of Resident to Resident abuse, as well as Failing to report the abuse allegation to the State Agency in the required time frame. The Immediate Jeopardy began on 1/22/13, was identified by the surveyor and reported to the AA on 1/31/13. The Immediate Jeopardy was corrected on 1/31/13, based on an acceptable plan of correction submitted by the facility on 1/31/13. The Plan of Correction included: 1. The 3-11 RN supervisor and the LPN will be relieved from the unit (will not be allowed into the building to work) until completion of investigation. The LPN and RN Supervisor will be monitored weekly for 2 months following their re-instatement. 2. Statements will be obtained from all staff present on the unit to conclude the investigation. All allegations of abuse will be fully investigated as per facilities Abuse Policy. 3. All staff will receive re-education on the abuse policy. 4. The incident will be opened as a project under the facilities Performance Improvement Committee. It will be monitored as a QA each month to ensure that the Abuse Policy, Procedure and Investigations are being followed and in compliance. The Administrator will be assigned this project. NJAC 8:39-4.1(a)5

C#'s: NJ & NJ Based on observations, interviews and review of medical records and other information, it was determined that the facility failed to consistently and adequately protect 3 of 3 residents assessed as an elopement risk (Residents #1, #2, #3). Although Resident #3 wore a Wanderguard (WG), she frequently bypassed (deactivated) the alarm on the secured (locked) unit's exit door despite staff's awareness of this behavior. On 8/10/12, Resident #3 opened and exited the door and Resident #1 followed Resident #3 out of the unit. Resident #1 then left the facility through the loading dock door. Resident #2 who resided on an unsecured (unlocked) unit, had verbalized desires to leave the facility and then eloped from the unsecured unit when a safety intervention (bed/chair alarm) was not implemented. After this elopement, Resident #2 was transferred to the secured unit, where Resident #3 continued to reside and was able to bypass the door alarm to exit and enter the secured unit. This resulted in an immediate jeopardy (IJ) situation for Residents #1, #2, #3 and potentially the 15 other residents, identified with elopement risk and/or wandering, who resided on the secured unit. The IJ, began on 8/10/12, was identified by the Surveyor and reported to the Administrator on 9/5/12 and corrected on the first day of survey 9/5/12, based on an acceptable plan of correction which was submitted by the facility. The evidence of this deficiency included: The Surveyor reviewed the medical records on 9/5/12 and 9/10/12. 1. Review of the Nursing Admission Assessment and History dated 8/10/12 indicated Resident #1 was alert and oriented to person only, had short term and long term memory impairments and was independent in transfer and ambulation. The physician's orders [REDACTED]. An Elopement Risk assessment dated [DATE] showed a score of "14" (10 or more indicating an elopement "risk"). The [DIAGNOSES REDACTED]. The Interdisciplinary Plan of Care dated 8/10/12 identified a risk for elopement secondary to "poor safety awareness, poor impulse control and cognitive defect." The goal indicated the Resident will be safe in the facility. Interventions included a Care Track or Wander Guard device (WG) worn on the left ankle, close distant observation and firm redirection. The Plan of Care also indicated that Resident #1 was a potential risk for falls/injury related to cognitive deficits, poor safety awareness and poor impulse control. Interventions included firm redirection, supervision distant and close and simple direct communication. A Reportable Event Record/Report dated 8/11/12 and other information faxed to the Department of Health (DOH) indicated that on 8/10/12 at 3:30pm, Resident #1 exited the (secured) unit's main entrance door without the alarm sounding and then exited the facility through the loading dock door. Once outside near the employee parking lot, the Resident approached staff and asked them how to get to another state. The staff escorted the Resident into the facility. The Interdisciplinary Progress Notes (IPN) dated 8/10/12 indicated that the Resident was admitted at 11:30am, was pleasantly confused and "wanders independently". A WG was placed on the Resident's left ankle. A subsequent entry dated 8/10/12 at 4:45pm documented that the Resident exited the door dressed in street clothes and that the WG was in place "but did not sound." The WG "worked upon re-entry, however battery changed and functional." The Resident was checked "Every 15 min (minutes)." The Unit's "Internal back-up alarms (were) activated." Further documentation dated 8/10/12 at 10:00pm to 8/11/12 at 7:45am indicated the Resident was "excessively checking exit doors (and) very restless" and the Resident's room was changed "for safety". The Surveyor reviewed the surveillance system on 9/5/12 at 10:50am, that corroborated the Associate Director of Nurses (DON #1) investigative summary dated 8/11/12 at 8:00am. DON #1 documented in the investigative summary that Resident #3 "exits and enters unit independently". On 10/5/12 at 10:00am the DON explained that the WG system on the secured unit's main door can be bypassed and opened without the alarm sounding. Resident #3 and Resident #1 were observed on surveillance film leaving the main door of the secured unit at the same time. Resident #3 continued to walk along the hall way while Resident #1 paused and turned to the left and exited the door leading to the loading dock. The DON confirmed that this door was not a magnetic or alarmable door and therefore the WG would not function at that door. Another surveillance view showed Resident #1 descend the steps and walk along the sidewalk. The Surveyor also observed that Resident #1 stopped walking as two employees approached and they appeared to have a conversation with the Resident. The employees were then observed escorting Resident #1 back into the facility. On 9/5/12 at 10:00am, DON #1 stated that on admission to the facility's secured unit a WG was placed on Resident #1's ankle because of a wandering history and risk of elopement. Resident #1 "followed ... Resident (#3) out of the unit " and even though both wore the WG bracelets there was no alarm sounding and both Residents walked through the secured unit's main door. This DON further explained that Resident #3 was aware of how to "bypass" the door. DON #1 verified that after walking through the secured unit's door, Resident #1 walked through the loading dock door and along the side walk for approximately 15 feet. Employees saw Resident #1 and returned her to the secured unit. The DON (#1) indicated, on 9/5/12 at 12:40pm, that the Resident looked like a visitor and the family said Resident #1 had "poor impulse control and would ambulate to exhaustion." 2. The Resident Assessment Instrument (RAI) dated 8/27/12 for Resident #3 documented a mental assessment score/BIMS of "8" (a range of 8 - 15) indicating a moderate cognitive impairment. This score was a decline from the annual RAI of 12/4/11 that indicated the Resident scored a "12" also a moderately impaired cognitive impairment. Comparison of the 8/27/12 and 12/4/11 RAI's showed recent improvement and no longer had "inattention" and daily wandering behaviors. The Face Sheet included [DIAGNOSES REDACTED]. The elopement assessment for Resident #3 showed a score "14" on 11/21/11, on 5/29/12 the score was "24" and 8/21/12 it was "16". These scores indicated a risk for elopement. During an interview on 9/5/12 at 6:40pm, the Associate Director of Nurses #2 (DON #2) acknowledged that the elopement risk protocol on the back of the elopement assessment form was "confusing" because of the way it was written. The Interdisciplinary Plan of Care, dated 3/5/12, indicated that the Resident had a problem related to "wandering with mild confusion" and was "at risk for elopement". Interventions dated 3/5/12 indicated that the Resident was to be "escorted to and from the unit by staff to visit ... (another resident in the facility), "attend activities in main rec (recreation) room, meals in MDR (main dining room) and to smoke". Evaluations dated 6/5/12 and 9/4/12 indicated the "goal met" and "cont'd (continued)." Another ongoing problem was a risk of injury secondary to cognitive decline, poor safety awareness, poor impulse control and pacing to exhaustion. Interventions included, a WG and close distant observation. Also Behavioral Disturbance or "verbal outburst" had a goal that Resident will "experience control of behavior with assistance from others". Interventions included "set limits" and "escort Resident to and from unit" to provide environment that provides safety and reduces agitation. According to the Interdisciplinary Progress Notes dated 7/9/12 at 8:15am Resident #3 was "confrontational and often agitated when asked to do things" such as "... waiting for escort to dining room etc." Additional documentation dated 7/14/12, 7/15/12, 7/19/12 and 7/22/12 indicated that Resident was "on and off" the unit at will and was "noncompliant with asking for escort." The Behavior Log and Monthly Summary dated 8/1/12 indicated "Resident (#3) was allowing another (resident) to leave through the door of the secured unit with her. Resident was holding open ... (the entrance door) for another (resident) to go to a resident counsel meeting." On 8/5/12 "Resident on + off unit ad lib", 8/6/12 "... Res. (Resident) ambulating throughout facility ad lib." On 8/16/12 "Res. Very demanding constantly on & off unit setting off alarms, demanding, stomping feet." On 9/5/12 at 4:15pm DON #1 indicated that Resident #3 was in the secured unit because of an attempt to leave the facility, but this DON could not recall the date. DON #1 also indicated that Resident #3 needed supervision because she had hit another resident and also was known to give food items to a resident, who was on a special diet. On 9/5/12 at 3:30pm DON #1 explained during tour of the secured unit how the WG door was "bypassed". From within the secured unit the Surveyor observed on the wall to the right of the main door, two boxes - the box closest to the door contained numbered key pad for code input. A box to the right of the key pad box had two buttons and when the two buttons were simultaneously pressed the Surveyor heard a mechanism within the door release and the door opened without the alarm sounding when a sample WG was held by DON#1. The Unit Manager (UM) of the secured unit explained on 9/10/12 at 10:50am that to get back into the unit, Resident #3 would press the button located on the wall outside of the main entrance to the unit. The UM confirmed that Resident #1 had a WG bracelet on and that her room was close to the secured unit's main entrance. The UM stated that she saw Resident #1 at the doorway of her room holding a hand bag and that Resident #1 may have saw Resident #3 going to the door and followed Resident #3 through the door. The Regular CNA stated on 9/10/12 at 11:00am that Resident #3 is escorted to the dining room, activity room (outside of the secured unit) or smoking area and is left on her own during the meal or activity. Sometimes the CNA or other staff escort Resident #3 back to the unit. The CNA confirmed that the Resident "knows to push the buttons to bypass the the door" and to "push the button" to reenter the secured unit. During interview on 9/10/12 at 11:15am, the Activity Person (AP) confirmed that Resident #3 "remembered how to get in and out" of the unit. The Resident "was suppose to be escorted out but when everyone is busy sometimes she lets herself out and in." The Social Worker (SW) stated on 9/10/12 at 4:00pm that she was not aware that Resident #3 could "bypass" the door and that she "heard" (Resident #3) was being "escorted" by staff out of and into the secured unit. The SW explained that the escort intervention was initiated at the same time the care plan entry was created. Review of the care plan showed an entry dated 3/5/12 that the Resident was to be escorted to and from the unit by staff. 3. The Nursing Admission Assessment and History dated 8/16/12 indicated that Resident #2 was alert to person only with short and long term memory impairment. Limited staff assistance was provided for bed mobility, transfers and extensive assistance needed for ambulation and most activities of daily living. The Resident was admitted into the rehabilitation unit (an unsecured unit). Also an indwelling catheter was in place for a neurogenic bladder. The [DIAGNOSES REDACTED]. The Elopement Risk assessment dated [DATE] showed a score of "11" which indicated a risk for elopement. The Interdisciplinary Care Plan dated 8/16/12 included "confusion and disorientation" related to Alzheimer Dementia, fall risk related to weakness and cognitive deficits with interventions for a chair sensor alarm. According to the IPN admission documentation dated 8/16/12 at 11:45am the Resident "has a band on ... (left) wrist 'Project Life Saver' - tracking bracelet". "Pt. (patient) states the police can find me if I wander away." Documentation also indicated that a "Bed alarm, chair alarm placed." Further documentation's dated 8/17/12 at 10:00pm indicated the Resident "very confused, anxious, non compliant with safety alarm - consistent ... (with) getting out of chair ..." "Resident also non-compliant ... (with) transfers - insists that she can walk by herself ..." On 8/20/12 at 6:30am the Resident "very confused and anxious". Refused all medications and was kept at nurses station for "half" the shift "for getting OOB (out of bed) by self ..." A 8/20/12 - 7:00am - 3:00pm shift note indicated the Resident "wants to go home." A Behavior Problem and Intervention Log dated 8/19/12 revealed noncompliance with safety, wandering, getting out of chair and bed and "wants to go home". The Behavior Log and Monthly Summary dated 8/20/12 - 7-3 shift indicated the Resident was "anxious, agitated, wants to go home, does not remember how she got here". "Needed freq (frequent) reminders and re-direction. Sat at desk most of shift for close observation for safety." Subsequent documentation dated 8/21/2012 - 11-7 shift indicated "Resident very confused. Wants to go home." "Looking for family ... redirected with little effect." During interview with the admitting Registered Nurse (RN) on 9/5/12 at 11:40am, the RN indicated that Resident was "cognitively okay" and "never saw" the Resident "as an elopement risk." While admitting the Resident into the facility on [DATE], a bracelet was observed on the Resident's wrist and the Resident "said the bracelet was in case I would go away." The RN indicated that she did not ask the Resident what that meant, nor did she explore with the family a history of wandering or elopement. The RN also stated that the next day the Resident presented with "some behaviors at dusk" and that the Resident "really seemed okay". DON #1 stated on 9/5/12 at 4:05pm that it was "felt" the Resident was "deconditioned and too weak to walk" the distance to get outside. The Certified Nurse Aide (CNA) on 9/5/12 at 11:50am, stated a bed/chair alarm was requested the day of Resident #2's admission because the Resident "didn't seem to understand direction and seemed to have a loss of awareness". It was also noted by the CNA that the Resident "could probably be a wander because ...(Resident #2) wanted to find ...(family member)". On 8/21/12 the Resident "thought she would be going home and said she wanted to go home". The CNA provided care and positioned the table in front of the Resident and went to get the breakfast tray. The CNA indicated that the Resident refused to allow the alarm to be in a place where it would function. When the CNA returned with the breakfast tray the Resident was not in the room and a search began. After a "couple minutes" the CNA saw staff returning Resident #2 to the room. A Reportable Event Record/Report dated 8/21/12 indicated that the Resident exited the facility "via employee entrance door." "These doors are continually monitored by security via visual and video monitoring. The security guard left the area to open the front door." The Resident "exited at 7:25am and returned at 7:35am". The Certified Nurse Aide (CNA) had left the Resident on the side of her bed and went to get the breakfast tray. The Resident was "identified as cognitively impaired but on admission she was without the stamina or endurance to ambulate for distances (such as outside)." The interventions focused on falls - cognitive impairment - UTI (urinary tract infection). We were using bed/chair alarms for her safety." The Reportable also indicated that upon return to the facility Resident #2 received checks every 15 minutes to ensure safety and at times one to one assistance. The Resident was then moved to the secured "locked" unit and "outfitted" with a WG. The Surveyor reviewed the surveillance system on 9/5/12 at 11:10am and corroborated the facility's investigation that showed the security guard leave the surveillance equipment room three times. The third time the security guard was away for approximately four minutes which coincided with Resident #2 carrying a urinary drainage bag as she walked along the hall way, exited the employee entrance and continued to walk along the concrete side walk. DON #2 documented in the Investigative Summary dated 8/21/12 that at approximately 7:35am two employees "spotted" the Resident walking outside of the building near the employee entrance that is located in the rear of the building. The Resident was "immediately escorted back" to the building. A physical assessment showed no injuries and the mental status remained at baseline. During interview on 9/10/12 at 11:55am, the Maintenance Director indicated that the Security people have to leave their post (surveillance system) to open doors at certain times during the day". Now maintenance "covers" the surveillance system while Security unlocks or opens the doors. Additional Investigative Summary documentation dated 8/21/12 at 8:15am indicated that staff saw the Resident walking outside of the facility carrying the urinary collection bag and was returned to the facility. The Resident was closely monitored, a WG was applied to the right wrist and was transferred to the secured unit. The Interdisciplinary Plan of Care was updated on 8/21/12 to include "risk for elopement". Interventions included transfer to the secured unit, monitor location at all times, bed and chair alarms and keep at nurses station as needed for observation. The Surveyor interviewed DON #1 on 9/5/12 at 4:10pm relating to the facility interventions to safeguard the other 15 residents that wander and/or are an elopement risk in the secured unit. This DON indicated that "in the morning meetings we spoke about ...(Resident #3) ability to leave the unit" and that "the Social Worker felt she needs" the secured unit. DON #2 stated on 9/5/12 at 10:40am that Resident #2 was not a "high elopement risk" on admission to the facility. She also stated that the security guard was "new" to the facility and that he left his post to do other duties and during this time no one was monitoring the surveillance system. The Policy entitled Elopement Risk Assessment indicated that if the assessment indicated a total score of 10 or greater, the resident should be considered to be at risk for elopement. The back of the Elopement Risk Assessment showed four sections: A. Low Elopement Risk - for score below "10" on risk assessment. Included in this category indicated "Listen to the resident if he/she voices a desire to leave". "Becomes more persistent" the resident "should be listed at high priority for elopement." B. Elopement Risk: - for a score of "10" or greater. This section included elopement watch and elopement warning C. Elopement Watch: Indicated "Document the resident's behavior if he/she makes any attempts to elope from the facility, interventions implemented and effectiveness." D. Elopement Warning: Indicated "The resident will be placed on the ... (WG) system to alert staff. The resident will be kept under close supervision for 24 hours and until the determination has been made they are no longer a flight risk. The Physician will be notified for evaluation. It may be necessary to find a more suitable facility for the resident." The IJ began on 8/10/12, was identified by the Surveyor and reported to the Administrator on 9/5/12 and corrected on the first day of survey, 9/5/12 based on an acceptable plan of correction which was submitted by the facility. 1. Resident #1's WG battery was immediately replaced and her room was moved closer to the nurses station and further from the exit door. The resident was monitored every 15 minutes for the remainder of the day. Activities has been instructed to provide more stimulation with activities to the resident's liking. 2. Resident #2 had a WG applied immediately and was placed at the nurses station with 1:1 attendant and 15 minutes checks by a nurse. The resident was transferred to the secured unit at 2pm on 8/21/12. 3. Effective 8/21/12 a procedural change was enacted. If the Security Guard must leave his post, Maintenance and/or the Nursing Supervisor will monitor the surveillance cameras. 4. Resident #3 was transferred to the unsecured unit on 9/5/12. Resident #3's Care Plan will be reviewed and revised as needed based on the assessments and staff re-education will be completed immediately and ongoing. 5. All identified wanderers are being reassessed as to their ability to bypass the safety doors through demonstration and by re-assessment using the BIMS/mini mental (Brief Interview Mental Status). The assessment was started 9/5/12 and completed tomorrow (9/6/12 by the "DON's"). If it is determined that a Resident has the capacity to bypass the security system then a Care Plan intervention will be immediately implemented. 6. All Residents are being evaluated at admission, quarterly and as needed to determine their need for placement on the secured unit. The "DON's" (DON# 1 and DON# 2) will be part of an Interdisciplinary Team that will determine the proper placement of Resident - either by moving to another Unit within the facility or discharge to an appropriate facility. 7. The Administrator will contact the Care Track Representative to secure a more updated/complex device used to bypass the security system. 8. A list of all identified wandering Residents will be created, reviewed and assessed for changes in their risk for elopement each day at morning report. The status of these Residents will be reviewed by the Interdisciplinary Team and needed Care Plan changes will be made. 9. The Elopement Policy will be updated and inserviced immediately to all staff. 10. This Plan will be started immediately (9/5/12) and the initial evaluation will be started and completed on 9/6/12. NJAC 8:39-27.1(a)

Based on observation, interview, record review and data provided by the facility, it was determined that the facility failed to provide care and services that promoted the prevention of pressure sores when limited joint mobility placed the resident at risk for impaired skin integrity. As a result, Resident #3 developed an avoidable, facility acquired pressure sore which required daily treatments, additional pain medication and antibiotic therapy. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed for pressure sores and was evidenced by the following: During the initial tour on 1/17/12 at 9:30 a.m., the surveyor observed Resident #3 lying in bed, with the left arm pulled up and resting on the chest. The resident was wearing protective coverings. The Unit Manager, who was accompanying the surveyor on the tour, said that Resident #3 had a contracture (an inability to straighten) the left arm and had recently developed a pressure sore on the inside of the left elbow, known as the antecubital space. A review of the resident's Wound Assessment Record identified that the pressure sore was first discovered on 1/3/12, and was located on the inner aspect of the resident's left elbow region. According to the Wound Assessment Record, this pressure sore measured 3 centimeters (cm) long, 5 cm wide and 0.1 cm deep. The wound was described as a deep tissue injury caused by pressure, which was foul smelling, painful and was accompanied by swelling around the edges of the wound. Photographs of the wound located in the Wound Assessment Record also identified the swollen area surrounding the wound as being red in color. On 1/3/12, the physician ordered daily treatments with Santyl (an ointment used to treat pressure sores), Keflex (an antibiotic) 500 mg by mouth 2 times daily and therapy and Tylenol with [MEDICATION NAME] #3 (narcotic pain medication) every 4 hours as needed for left arm pain. A review of the medical record identified that the resident had [DIAGNOSES REDACTED]. The resident also had a physician's orders [REDACTED]. The physician's orders [REDACTED]. According to the The Resident Assessment Instruments (RAIs), dated 2/7/11 and 11/7/11, Resident #3 had cognitive impairment, was dependent on staff for care and had no skin breakdown. Both RAIs also identified that the resident had no limitations in joint range of motion. A Rehabilitation Screen, dated 2/4/11, documented a contracture of the left elbow, and identified that the resident was on the facility's Restorative Nursing Program (RNP). On this program, the resident received services which included passive range of motion exercises 3 to 5 times a week. In an Occupational Therapy Plan Of Treatment note dated 5/17/11, an Occupational Therapist (OT) identified that the resident's left elbow contracture was fully flexed when at rest, and required gentle stretching to reach a 90 degree angle, "promoting hygiene and skin integrity". The OT also wrote that the resident was to continue to receive RNP services, which included pillow positioning (using a pillow in the crease of the arm to extend it, which also reduces both pressure and the accumulation of moisture) and range of motion exercises to left elbow. On 1/18/12 at 8:10 a.m., the surveyor again observed the resident sitting in a specialized chair, wearing the same protective coverings on both arms. The resident's left arm was still flexed tightly at the elbow and held against the chest and the resident was using the right hand to scratch the inner area of the left elbow, which was protected by a dressing underneath the protective sleeves. When interviewed, by the surveyor, on 1/18/12 at 10 a.m., the Unit manager said that the CNAs (Certified Nursing Assistants) caring for the resident were to remove the skin sleeves and inspect the skin at least 2 times a day, during morning and evening care. According to a nurse's note dated 1/3/12, the pressure sore was not identified until a CNA, who was giving the resident a shower, observed blood oozing from the crease of the resident's left elbow. The content of the nurse's note was verified by the Unit manager at that 10 a.m. on 1/18/12. On 1/18/12 at 11 a.m., the CNA caring for the resident said that the CNAs referred to the care plans, located at the nurses station, to obtain information regarding resident care and any special needs. Upon review, there were no documented interventions, such as skin inspections following the removal of the skin sleeves. According to the facility's Nursing Care Policy, a resident's skin was to be inspected daily by the CNA. However, when interviewed on 1/19/12 at 3 p.m., the Director of Nursing (DON) was unable to confirm that staff had inspected the resident's skin every day when the skin sleeves were removed for care. The DON also said that the Treatment Administration Record (TAR) contained documentation that the nurses conducted skin inspections when the sleeves were removed for morning and evening care. However, a review of the 1/2012 TAR failed to identify that skin inspections were being done. In a follow up interview on 1/20/12 at 8:45 a.m., the Unit Manager said that nurses only did routine skin inspections weekly for the first month following a new admission. After that, the nurses relied on the nurses aides to identify and report any skin problems. According to the medical record, Resident #3 had been a resident in the facility since 2003. In an interview on 1/20/12 at 10 a.m., the Unit Manager said that residents on the RNP received rehabilitation screenings by a therapist on at least quarterly basis to determine ongoing treatment. On 9/16/11, a Licensed Practical Nurse (LPN) RNP coordinator, documented in the Restorative Nursing Log that the resident's RNP program had been discontinued because the resident was "not benefiting from the program" and "no improvements (were) noted." There was no documented rehabilitation screen performed to make this determination. On 1/18/12 at 10 a.m., the Unit Manager said that the resident had been cut from the program due to facility budget cuts and subsequent staffing cuts in the program. There was no documented evidence that range of motion exercises or pillow positioning was continued by the unit staff following the discontinuation of RNP services. In an interview on 1/19/12 at 3 p.m., the Director Of Nursing (DON) said that staff should have continued to use a positioning device to keep the left arm open. On 1/4/12, the Physician ordered that the RNP be restarted as previously set up by the rehabilitation staff, with slow, gentle sustained range of motion exercises to the left elbow as tolerated and pillow positioning as able. On 1/18/12 at 8:10 a.m., the surveyor observed the resident's pressure sore in the presence of the treatment nurse and a Certified Nursing Assistant. During the treatment observation, the CNA was able to partially open the resident's flexed, left elbow while speaking softly to the resident and using gentle movements. NJAC 8:39-27.1(e) NJAC 8:39-27.2(m)

C# C# A.) Based on observation, interview, review of the medical record and review of data provided by the facility, it was determined that the facility failed to provide timely care and services to a resident who presented with an injury to the left leg. The injury was first observed, by a Licensed Practical Nurse (LPN), on 12/25/11, however, the injury was not assessed by a Registered Nurse (RN). In addition, it was not until 12/26/11 that the resident's physician was notified of the injury, which was subsequently diagnosed as fractures of the tibia and fibula bones of the left leg. The lack of an assessment and investigation, the delay in physician notification and the delay in treatment resulted in 1 of 4 residents sampled for fractures (Resident #1) experiencing actual harm. This deficient practice was evidenced by the following: During the initial tour of the TLC Unit on 1/17/12 at 10 a.m., the Unit Manager said that Resident #1 had End Stage Dementia, contractures of both legs, and had sustained a left foot fracture on Christmas Day. The Unit Manager explained that the TLC Unit had closed due to a low census and Resident #1 had been temporarily living on another Unit when the fracture occurred. On 1/23/12 at 12 p.m., the surveyor observed the resident lying in bed. Both of the resident's legs were bent at the knees. During a subsequent observation on 1/19/12 at 8:45 a.m., the surveyor observed the resident's legs in the presence of the LPN on the TLC Unit. Both legs were bent at 90 degree angles at the knees and there was an orthotic splint present on the resident's left lower leg, extending from the knee to the toes. The LPN said that the resident was unable to straighten the legs any further. A review of the medical record revealed that Resident #1 was transferred from the TLC Unit to the East Unit on 12/19/11. In a nurses note dated 12/25/11 at 10:45 p.m., an LPN wrote that the resident had swelling in the left ankle, which was warm to touch, and which elicited moaning with palpation. According to this note, the LPN administered pain medication, and elevated the left leg on a pillow. No further action was documented. There was no documented evidence that the LPN notified the Registered Nurse (RN) on duty and no documented assessment by an RN. In addition, there was no documented evidence that the physician or family was notified of the resident's symptoms and no documented monitoring of the left lower leg throughout the night. In the next nurses note, dated 12/26/11 at 6:30 a.m., another LPN wrote that the resident had increased swelling of the left ankle accompanied by bruising and symptoms of pain with palpation, and had been given pain medication at 4:30 a.m. during that shift. The LPN wrote in the entry that the supervisor was notified and added that the oncoming supervisor would be notified as well. Again, there was no documented assessment by any RNs or that the physician or family was notified of the resident's symptoms. During review of the medical record, the surveyor observed that it was not until 12/26/11 at 9 a.m., that an LPN documented that a call was placed to the resident's physician regarding the resident's change in condition. The LPN received orders at 9:05 a.m. to obtain an Xray of the left ankle and foot and a venous Doppler study. This nurses notes also revealed that the facility had not notified the family until 9:15 a.m. on 12/26/11. A nurses note dated 12/26/11 at 1 p.m. indicated that the physician came to examine the resident and that the diagnostic tests were completed at the facility. This note indicated that the X-rays revealed that the resident had a [MEDICATION NAME] distal tibia and fibula with slight lateral displacement. A nurses note dated 12/26/11 at 2:30 p.m. indicated that the resident was transferred to the hospital for treatment at 2:00 p.m. that same day. A review of the facility's investigation identified that a Certified Nursing Assistant (CNA) had noted the change in condition of the resident's left ankle and reported it to the nurse at 8 p.m. on 12/25/11, not 10:45 p.m. as documented by the LPN. Written statements that were obtained by the night shift LPN and RN supervisor indicated that an RN assessed the resident to determine if further action should be taken. However, there was no documented evidence in the resident's medical record that this had been done. B.) Based on observation, interview, medical record review and review of data provided by the facility, it was determined that the facility failed to identify risk factors, provide adequate care and hydration and accurately monitor the elimination patterns to prevent the avoidable development of fecal impactions and/or constipation for 3 of 3 residents (Residents #15, #16 and #25) who were sampled for fecal impaction. As a result, 1 of the 3 sampled residents (Resident #16) had to be treated for [REDACTED]. This deficient practice was evidenced by the following: 1. On 1/18/12 at 9:00 a.m., the surveyor observed Resident #16 sitting in bed, awake and alert. The resident's breakfast tray was in front of the resident, however, the 4 ounce container of OJ had not been opened. When interviewed at this time, the resident stated that she liked cold cereal, milk, OJ and coffee for breakfast. Surveyor review of Resident #16's drug regimen showed that Resident #16 had a physician's orders [REDACTED]. According to the manufacturers' information, [MEDICATION NAME] and [MEDICATION NAME] can cause constipation and [MEDICATION NAME], an [MEDICATION NAME], can cause both dry mouth and constipation. The resident also had an order to receive 10 milligrams (mg) of Ducolax every night and 100 mg of [MEDICATION NAME], a stool softener, twice a day. According to an Interdisciplinary Progress Note (IDPN) dated 12/25/11 at 1400 (2:00 p.m.), Resident #16 was "noted to have distended abd. (abdomen)" and no bowel sounds in all quadrants of the abdomen. LPN #1, who wrote this note, documented that the resident's abdomen was slightly hard" and had "soft BM/stool impaction." LPN #1 wrote that a Ducolax suppository was given and that the results from the Ducolax suppository were "pending." On 12/25/11 at 2230 (10:30 p.m.), LPN #2 wrote that the resident was given a fleets enema at 2000 (8:00 p.m.). A small amount of BM was observed. LPN #2 wrote that Resident #16's abdomen "still noted distended" and there were no bowel sounds in all 4 quadrants of the abdomen. On 12/26/11 at 0430 (4:30 a.m.), LPN #3 wrote that the resident's abdomen was distended and that the upper left quadrant of the abdomen was "hardened." LPN #3 documented that the resident had "hypoactive" bowel sounds in all 4 quadrants and that there was "no BM as of this time." At 0615 (6:15 a.m.), LPN #3 documented that Resident #16 had a "smear of BM and remains the same. Will notify AM supervisor." There was no documentation, as of 12/26/11 at 6:15 a.m., that Resident #16 was assessed by a Registered Nurse (RN) or that the resident's physician was notified. On 12/26/11 at 0730 (7:30 a.m.), LPN #4 documented that she spoke with Resident #16's attending physician who ordered that the resident be sent to the ER for the lack of bowel sounds and no results from "MOM, Ducolax Suppos and fleets." The surveyor reviewed the resident's Medication Administration Record (MAR) and there was no evidence that Milk of Magnesia (MOM), a Ducolax suppository or a fleets enema were administered. According to LPN #4's documentation, the ambulance and the emergency room were not called regarding Resident #16 until 0900 (9:00 a.m.), an hour and a half after the resident's physician gave the order to transfer the resident to the ER. According to the IDPN, dated 12/26/11 0925 (9:25 a.m.), Resident #16 was transported to the local hospital emergency room . According to the emergency room records, that were provided by the facility, Resident #16 complained of abdominal pain that had been occurring for "1 day." The records also indicated that the resident's abdomen was "distended" and "firm." An Obstructive Series was conducted at the hospital. The images of the resident's bowel that were seen during the test indicated that there was "extensive fecal debris present with prominent colonic dilatation...implying the presence of a extensive impaction." The findings were consistent with "an extensive rectosigmoid impaction." The resident was subsequently discharged from the hospital and was admitted back to the facility. According to an IDPN, dated 12/26/11 2240 (10:40 a.m.), a nurse documented that she was informed by a Certified Nursing Assistant (CNA) that Resident #16 had an extra large BM "but was still impacted." This IDPN indicated that the "desk nurse examined resident further; rectum very dilated." The nurse documented that a fleets (enema) was given to Resident #16 with positive results but the rectum was still dilated and BM was "still present." On 12/27/11 0615 (6:15 a.m.), LPN #3 documented that the resident's abdomen remained distended but soft and that the resident had a BM. On 12/27/11 1430 (2:30 p.m.), LPN #4 documented that Resident #16 had a "XXX lg BM." According to the attending physician's progress note, dated 12/30/11, Resident #16 had a "severe impaction" and was sent to the "ER". The surveyor reviewed Resident #16's medical record which revealed a Registered Dietitian (RD) note, dated 1/11/12 (untimed). There was no documentation in the RD's note addressing the resident's "severe impaction" in December of 2011. The surveyor reviewed the "BM/LAX./Enema Tracking Form" that was provided by the facility which revealed that Resident #16 had only "smears" of BM documented on 12/21/11, 12/24/11 and 12/25/11. There was no documented BMs for Resident #16 on 12/20/11, 12/22/11 and 12/23/11. When the surveyor reviewed the December 2011 MAR on 1/20/12 at 12:22 p.m., it revealed documentation that MOM was administered to Resident #16 on 12/9/11 only and that a Ducolax suppository was administered to the resident on 12/18/11 only. There was no documentation on this MAR that MOM, the suppository, or the enema were administered at all from 12/25/11 through 12/27/11. 2. According to the January 2012 physician's orders [REDACTED]. There was also an order [REDACTED]. According to an Interdisciplinary Progress Note dated 1/9/12 at 2215 (10:15 p.m.), Resident #15 "had a mod. impacted BM @ HS (Hour of Sleep). Suppository given by TX (Treatment) nurse; results pending for further BM's." A review of the resident's January 2012 MAR revealed that a [MEDICATION NAME] suppository was administered on 1/9/12, however, there was no documentation regarding the results of the suppository. In addition, there was no documentation in the MAR that MOM was administered prior to the use of the suppository. A further review of the January 2012 MAR revealed that, in addition to the [MEDICATION NAME] suppository that was administered to the resident on 1/9/12, there was MOM administered on 1/5/12, and [MEDICATION NAME] suppositories administered on 1/20/12 and 1/21/12. There was no documentation in the Interdisciplinary Progress Notes indicating that an assessment was conducted for "hydration and other interventions to promote good elimination patterns" as per the facility's "Bowel Program" policy. 3. When interviewed on 1/23/12 at 2:30 p.m., Resident #25, who was alert and oriented, stated that she occasionally had trouble moving her bowels. Resident #25 stated that she had to "push" when she was "constipated" and sometimes there was bleeding after she had a BM. A review of the December 2011 Medication Administration Record (MAR) revealed that Resident #25 received a [MEDICATION NAME] suppository on 12/4/11. According to this same MAR, Resident #25 received MOM on 12/3/11, 12/13/11 and 12/16/11. A review of the "BM/LAX./Enema Tracking Form" that was provided by the facility revealed that Resident #25 did not have a documented BM for 5 days from 12/9/11 through 12/13/11, when she received a 30 ml of MOM. The resident did not have a documented BM from 12/15/11 through 12/18/11. On 12/18/11, there was documentation on the "BM/LAX./Enema Tracking Form" that the resident had received MOM but this medication was not documented as administered on the December 2011 MAR for this date. Resident #25 did not have a documented BM from 12/23/11 until 12/26/11. On 12/26/11, there was documentation on the "BM/LAX./Enema Tracking Form" that the resident had received MOM but this medication was not documented as administered on the December 2011 MAR for this date. The resident had no documented BM from 12/27/11 through 12/29/11, however, there was no documentation that she had received any laxative per the facility's "Bowel Program" policy. Surveyor review of Resident #25's drug regimen showed that Resident #25, who had [DIAGNOSES REDACTED]. The resident also had a physician's orders [REDACTED]. According to the manufacturers' guidelines, [MEDICATION NAME], Ferrogels and [MEDICATION NAME] can cause constipation. [MEDICATION NAME] and [MEDICATION NAME] can cause a dry mouth and constipation. According to the January 2012 physician's orders [REDACTED]. 4. A review of the "BM/LAX./Enema Tracking Form" for Resident #15 revealed that the resident did not have a documented BM at all on 12/26/11, 12/27/11 and 12/28/11. The documentation indicated that the resident did not have a BM until the day shift of 12/29/11. There was no indication on the "BM/LAX./Enema Tracking Form" or the MAR that MOM was administered to Resident #15 after having no BM for 72 hours. Surveyor review of Resident #15's drug regimen showed that Resident #15 had a physician order [REDACTED]. According to the manufacturers' guidelines, all 4 medications can cause constipation and [MEDICATION NAME] can cause dry mouth as well. According to the facility's "Bowel Program" policy, the following were included in the "Procedure" section: a.) The "3-11 Charge Nurse will review the BM sheet at the beginning of the shift to assess needs for bowel interventions;" b.) "The Medication Nurse will document the laxative given on the MAR and the BM Sheet;" c.) "The 11-7 Charge Nurse will monitor for results from the laxative list. When no results have occurred during the 11-7 shift the nurse will do a rectal exam and rectal suppository given as required. Results will be documented on the MAR and BM Sheet;" d.) "The 7-3 Medication Nurse will monitor for results of the rectal suppository and document results on the MAR and BM Sheet;" e.) "Residents who utilize the laxative for elimination three (3) times a month will be assessed for hydration and other interventions to promote good elimination patterns;" and f.) "Documentation of the assessment will be located in the Interdisciplinary Progress Note." NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to develop an Interdisciplinary Care Plan to maintain the skin integrity of a resident with impaired range of motion. This deficient practice contributed to the development of a facility-acquired pressure sore for a sampled resident (Resident #3). The deficient practice was also identified for Resident #16, who developed a fecal impaction that required emergency treatment at the local hospital emergency room and for Residents # 11 and #12, who experienced a decline in their continence. The evidence for the 4 of 25 residents (Residents #3, #11, #12 and #16) reviewed during the survey was as follows: 1.) During the initial tour on 1/17/12 at 9:30 a.m., the Unit Manager accompanying the surveyor stated that Resident #3 was unable to straighten the left arm due to a contracture, and had developed a facility acquired pressure sore on the inner aspect of the left elbow. A rehabilitation screen, dated 2/4/11, indicated that Resident #3 had impaired range of motion in the left elbow. However, the Resident Assessment Instrument (RAI), dated 2/14/11, failed to identify the presence of the contracture. The corresponding Care Area Assessment (CAA) addressed risk factors for developing pressure sores related to incontinence and immobility, but failed to include an in-depth assessment of risk factors for skin breakdown associated with the contracture. In addition, the Interdisciplinary Team failed to establish an individualized plan of care to prevent skin breakdown in this area. The surveyor reviewed the medical record which indicated that Resident #3 was receiving services under the Restorative Nursing Program (RNP) for the contracture, which included interventions of pillow positioning to keep the left elbow from closing too tightly, causing pressure and range of motion exercises to promote joint mobility, thus relieving pressure. When the resident's RNP services were discontinued on 9/16/11, there was no comprehensive plan of care in place to prevent skin breakdown in the area of the contracture. A Wound Assessment Record, dated 1/3/12, identified that Resident #3 had developed a facility-acquired pressure sore, measuring 3 centimeters (cm) long by 5 cm wide by 0.1 cm deep. This pressure sore was also described as foul smelling, painful, and with tissue swelling surrounding the wound. A corresponding physician's orders [REDACTED]. (Refer to F-314) 2.) According to the medical record, Resident #16 experienced an avoidable fecal impaction on 12/25/11 that required evaluation and treatment at the local hospital's emergency roiagnom on [DATE]. Once the impaction was relieved on 12/27/11, there was no plan of care developed to prevent the reoccurrence of the fecal impaction. 3.) According to the initial RAI, dated 8/23/11, Resident #11 was continent of urine. A review of the quarterly RAI, dated 11/22/11, revealed that the resident was frequently incontinent of urine. There was no documentation in the medical record acknowledging or addressing the decline. When interviewed on 1/20/12 at 11:05 a.m., the RAI coordinator stated that she was aware of the resident's decline in urinary continence and was going to follow up on it but didn't. When interviewed on 1/20/12 at 2:16 p.m., the Director of Nurses stated that there was no formalized program for residents' toileting needs. A review of the plan of care revealed that the only documentation related to Resident #11's decline in continence status was that both continent and incontinent were checked under the heading of "Bowel/Bladder". The section for "Toilet Schedule" was blank. There were no interventions or goals related to an attempted restoration of Resident #11's continence level. 4.) According to the initial RAI, dated 7/1/11, Resident #1 was always incontinent of urine. A review of the quarterly RAI, dated 12/27/11, revealed that the resident was frequently incontinent of urine. Both assessments indicated that Resident #12 was on a toileting program but there was no documentation, in the medical record or plan of care, indicating that the resident had a toileting program. The surveyor reviewed the plan of care which revealed that the only documentation related to Resident #12's continence status was that the resident was incontinent under the heading of "Bowel/Bladder" and that the resident would be toileted before meals, at night and whenever necessary. When interviewed on 1/20/12 at 2:16 p.m., the Director of Nurses stated that there was no formalized program for residents' toileting needs. According to the facility's "Bowel and Bladder Re-training & Toileting Assessment," any resident who experiences a change in continence would have "an assessment to determine the plan of care." NJAC 8:39-27.1(f)

Based on observation, interview and record review, it was determined that the facility failed to conduct accurate assessments mandated by the State agency. The lack of accurate assessments in which Resident #3 was incorrectly identified as having no functional limitations, contributed to the development of a facility-acquired pressure sore. The lack of an accurate assessment was also identified for Resident #18 who had bilateral contractures of both lower extremities. This deficient practice was identified for 2 of 28 residents sampled (Residents #3 and #18) whose Resident Assessment instruments (RAIs) were reviewed during the survey and was evidenced by the following: 1. During the initial tour on 1/17/12 at 9:30 a.m., the Unit Manager accompanying the surveyor identified that Resident #3 was unable to straighten the left arm, and had developed a pressure sore located on the inner aspect of the left elbow while residing in the facility. According to a rehabilitation screen dated 2/4/11, Resident #3 was only able to straighten the left elbow to 90 degrees, instead of a full 180 degrees. The Annual RAI dated 2/14/11, inaccurately identified that the resident had no functional limitations to the upper extremities. The corresponding Care Area Assessment (CAA) Summary failed to identify the resultant potential for skin breakdown. Since this was not done, the decision for additional care planning to maintain skin integrity in this area was not established. The most recent RAI, dated 11/7/11 continued to inaccurately identify that the resident had no functional limitations with no identified care plan to prevent pressure sores in this area. According to Wound Assessment Records, on 1/3/12 Resident #3 developed a facility-acquired pressure sore, measuring 3 cm long, by 5 cm wide, by 0.1 cm deep, which was described as foul smelling, painful, and with tissue swelling surrounding the wound. The corresponding physician's orders [REDACTED]. (Refer to F-314) 2. During the initial tour on 1/17/12 at 9:40 a.m., the Unit Manager said that Resident #18 had contractures of both legs and wore braces. On 1/19/12 at 9 a.m., the surveyor observed the resident seated in a recliner, with both legs flexed and with braces in place on both legs. According to a Rehabilitation Screen, dated 9/22/11, Resident #18 had contractures of both lower extremities. However both the 9/12/11 and 12/12/11 RAIs inaccurately identified that the resident only had a functional limitation on 1 lower extremity. NJAC 8:39-27.1(a)