Every finding on record at Crestwood Manor

Based on record review, interviews, and policy review, the facility failed to ensure documentation of cardiopulmonary resuscitation (CPR) status for five out of 14 residents reviewed for advance directives (Resident (R) 16, R34, R56, R6, and R41) out of a total sample of 21 residents. This failure created a risk that residents would receive CPR or other life-sustaining interventions that were inconsistent with their expressed wishes, potentially resulting in unwanted treatment, emotional distress, and compromised quality of care.Findings include:1. Review of the undated Face Sheet in the electronic medical record (EMR) under the Admissions tab revealed R16 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the admission Minimum Data Set (MDS) in the EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of [DATE], revealed R16 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she was cognitively intact. Review of the Resident Medication Summary in the EMR under the Orders tab revealed R16 did not have any physician orders regarding CPR status. Review of R16's EMR and paper chart revealed no documentation of the resident's CPR preferences. During an interview on [DATE] at 2:30 PM, R16 stated he/she was in the process of moving back to the assisted living part of the facility that day. When asked if he/she had a living will or advance directive, R16 stated that he/she had a Do Not Resuscitate (DNR) order in her medical chart in the assisted living. 2. Review of the undated Face Sheet in the EMR under the Admissions tab revealed R34 was admitted to the facility on [DATE]. Review of the admission MDS in the EMR under the RAI tab with an ARD of [DATE] revealed R34 had a BIMS score of 11 out of 15, indicating he/she had moderate cognitive impairment. Review of the Resident Medication Summary in the EMR under the Orders tab revealed R34 did not have any physician orders regarding CPR status. Review of R34's EMR and paper chart revealed no documentation of the resident's CPR preferences. During an interview on [DATE] at 12:20 PM, R34 reported that he/she wanted the facility to perform CPR in the event he/she was found without a pulse. 3. Review of the undated Face Sheet in the EMR under the Admissions tab revealed R56 was admitted to the facility on [DATE]. Review of the admission MDS in the EMR under the RAI tab with an ARD of [DATE] revealed R56 had a BIMS score of four out of 15, indicating he/she had severe cognitive impairment. Review of the Resident Medication Summary in the EMR under the Orders tab revealed R56 did not have any physician orders regarding CPR status. Review of R56's EMR revealed progress notes indicating full code status. 4. Review of the admission MDS located under the RAI tab of the EMR revealed that R6 was admitted on [DATE] and had a BIMS score of 14 out of 15, indicating he/she was cognitively intact. Diagnoses included cancer. Review of R6's EMR revealed no indication of his/her code status. During an interview on [DATE] at 12:15PM, R6 stated that he/she wanted everything to be done by the facility to keep him/her alive. R6 stated the lady that works here had already talked to him/her about that when he/she first came to the facility. 5. Review of the admission MDS located under the RAI tab of the EMR revealed that R41 was admitted on [DATE] and had a BIMS score of 14 out of 15, indicating he/she was cognitively intact. Diagnoses included coronary artery disease and diabetes mellitus. Review of R41's EMR revealed no indication of his/her code status. During an interview on [DATE] at 12:30PM, R41 stated that he/she wanted the facility to perform CPR in the event he/she was found without a pulse. During an interview on [DATE] at 10:52 AM, the admission Coordinator (AC) stated the process for obtaining a resident's code status on admission included reviewing hospital discharge records and requiring the resident or family member to complete the admissions packet, which indicated whether advance directives had been discussed. If available, residents or families were asked to provide a living will or a Durable Power of Attorney (DPOA). The AC stated that he/she, along with the nursing staff and the social worker, shared responsibility for ensuring that each resident's code status was documented in the residents' medical records. When asked to identify the code status for R6, R16, R34, R41, and R56, the AC was unable to locate this information in the EMR or in the residents' paper chart binders. The AC said he/she did not know how the code status documentation for these residents was missing. He/she further stated that some of the residents were admitted from the assisted living hallway, and the code status information could be found in the assisted living documentation. The AC indicated that in the absence of a documented code status in the EMR, a resident would automatically be treated as full code, with all life-saving measures implemented. During an interview on [DATE] at 11:10 AM, Registered Nurse (RN) stated he/she was unaware that the code status was missing from the medical records and confirmed the findings identified by the AC. The five residents, all admitted within the previous 30 days, did not have a documented code status and lacked documentation of a DPOA, advance directive, or Practitioner Orders for Life-Sustaining Treatment (POLST). The RN stated that in the absence of a documented code status, the resident's status automatically defaulted to full code, indicating that all life-saving measures would be initiated. During an interview on [DATE] at 1:46 PM, the Director of Nursing (DON) stated that he/she was aware that multiple residents had been identified as lacking a documented code status. He/she stated that multiple staff shared the responsibility for ensuring residents had the required documentation for code status or advance directive. The DON further stated it was his/her expectation that one designated person should be responsible for auditing all the EMRs to ensure compliance with documentation requirements. During an interview on [DATE] at 2:55 PM with the Medical Director and the Administrator, the Medical Director stated most of the residents admitted to the facility were previous patients of his/hers and that his/her records would indicate a code status that should be entered into the EMR upon the residents' admission to the nursing facility. Review of the facility's policy titled, Advanced Directives Policies and Procedures, revised [DATE], documented that a facility designee would be responsible to provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to formulate advance directives and information about whether the resident had executed an advance directive would be displayed prominently in the medical record upon admission or prior to admission to the facility. Advance directives were defined as preferences regarding treatment options and included Living Wills, Do Not Resuscitate, and POLSTs. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. NJAC 8:39-14.2(b)

Based on observations, interviews, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) and failed to handle soiled linen in a manner to prevent cross contamination for one of 21 sampled residents (Resident (R) 10) reviewed for infection control. These failures placed all residents of the facility at risk for the transmission and spread of infections. Findings include: Review of the facility provided Face Sheet indicated the R10 was re-admitted to the facility on [DATE] with a diagnosis of multiple myeloma and stress fracture. Review of facility provided Progress Notes, dated 08/26/25, indicated, Patient diagnosed with stress fracture, orders to place Foley [indwelling urinary] catheter received.Review of facility provided Physician Orders, dated 09/04/25, indicated, EBP for Foley.During initial tour observation on 03/09/26 at 11:00 AM, a catheter bag was observed hanging on the left side of the bed, facing the wall; however, no EBP sign and no personal protective equipment (PPE) was observed in the area on or around the door. A Hospice Aide (HA) was in the room removing linens from R10's bed. HA was not wearing a gown and had placed soiled linen on the floor without a barrier. Approximately five minutes later, HA picked up the soiled linen and carried it with gloved hands, without placing it in a bag or other container, to the soiled bins near R10's room.Observation on 03/09/26 at 1:46 PM revealed R10's catheter bag was hanging on the left side of the bed towards the wall. There was no evidence of an EBP sign on R10's bedroom door. There was no evidence of a bin with PPE outside the room. Observations on 03/10/26 at 5:08 PM, 03/11/26 at 10:30 AM and 2:30 PM, and 03/12/26 at 11:00 AM revealed no evidence of an EBP sign on R10's bedroom door and no evidence of an EBP bin outside the room with PPE. During an interview on 03/12/26 at 12:08 PM, HA said that he/she had been coming to the facility for the past three weeks and working with R10. He/she confirmed that the facility had not provided any specific information about R10. HA stated that he/she wore gloves and a mask during care, but not a gown. He/she was unsure what EBP was and what to wear when providing care. The HA confirmed that he/she did not bag the soiled linen on 03/08/26 and should have before walking out of R10's room.During an interview on 3/12/26 at 12:19 PM, the Director of Nursing (DON) stated that the Infection Preventionist (IP) gave him/her a weekly list that includes all residents on EBP and the reason. Also, the list was updated as needed. The DON stated that there was a white board at the nursing station with dots by the names of the residents on EBP, there were Rubbermaid boxes with PPE outside those residents' rooms, and there were EBP signs on the doors alerting staff and visitors. The DON was unsure if there had been any EBP training lately for hospice aides. The DON stated that the expectation of hospice aides would be to not have soiled linen on the floor without a barrier and to not carry soiled linen out of a resident's room without it being in a bag. During an interview on 3/12/26 at 12:40 PM, the IP said that training on EBP was completed when someone new was at the facility; however, the IP denied any new hospice aides in the last three to four weeks. The IP stated that during catheter care staff should be wearing gowns and gloves. Also, the residents had colored dots by their names on the doors that coordinated with the white board at the nursing station. The IP stated that a non-Multidrug-Resistant Organism (MDRO) was a yellow dot. She indicated that an isolation cart with appropriate PPE was outside the rooms and stated that no soiled linen should be removed from an EBP room, stating there should be two black trashcans side by side, one for soiled linen and one for garbage inside the room. The IP stated that no soiled linen was allowed on the bare floor at any time and should not be carried out in the hall without being in a bag. During R10's room observation on 03/12/26 at 1:00 PM with the DON and IP, the DON and IP both confirmed that there was no EBP cart outside of the room with appropriate PPE, no EBP sign on door, no yellow dot beside R10's name on nameplate, and no black trash cans inside the room. Review of facility's policy titled, Personal Care Policies and Procedures, revised 02/26/12, indicated, . Procedure: . 2. Remove soiled linen from the bed, place in plastic or resident's hamper. Do not hold linen against your clothing . Review of facility's policy titled, Infection Control Policies and Procedures, revised 04/15/25, indicated, EBP is an approach to the use of PPE to reduce transmission of MDROs between residents in skilled nursing facilities (SNF). EBP expands the use of gowns and gloves beyond standard precautions for anticipated blood and body fluid exposures. This strategy calls for healthcare personnel (HCP) to wear specific PPE during high contact resident care activities for residents known to be infected or colonized with an MDRO as well as those at increased risk of MDRO acquisition . Procedure: 1. [NAME] gown and gloves during high contact resident care activities that result in transfer of MDROs to hands and clothing of HCP, even if blood and body fluid exposure is not anticipated . 4. EBP can be applied to residents with any of the following when contact precautions do not otherwise apply: . b. wounds or indwelling medical devices, even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include but are not limited to: . Urinary catheters . 6. High contact resident care activities include, but are not limited to . d.) changing linens . NJAC 8:39-19.4

Based on observation, interviews, and review of facility documentation it was determined that the facility failed to a.) properly label, date and store potentially hazardous foods in a manner that is intended to prevent the development of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 09/03/24 at 08:30 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD) and the facility Executive Chef (EC). The surveyor observed the following: The Preparation Box refrigerator contained a 1 (one) gallon container of thousand island dressing and a 1-gallon container of tartar sauce with no opening date or use by date. The FSD was interviewed at this time and stated that the importance of having an opening date and a use by date was to ensure that the product freshness was maintained. The surveyor inspected the dry storage closet that contained a 15-pound container of dry liquid thickener with a use by date of 08/15/24. The FSD was interviewed at this time and stated that it was important to ensure that all products had an opening date and a use by date to ensure that the product was fresh and did not go stale. He stated that he would discard the thickener because it was past the use by date. The produce refrigerator contained a large hotel container filled with whole peppers with a use by date of 08/24/24 and 9 (nine) 16-ounce bags of carrots with a use by date of 08/16/24. There was also a large cardboard box of kale with no received date or use by date labeled on the box. The EC was present at this time and stated that the produce was past the used by date and would have to be discarded. The surveyor observed a large plastic container of flour with the scooper left inside the container. The FSD stated that the scooper should not be left inside of the container as it could potentially contaminate the flour. The commercial can opener was observed with sticky brown substances on the shaft and pointed blade that inserted into the can. The EC stated at this time, that the can opener was usually cleaned daily. When the surveyor asked the EC for the Master Cleaning Schedule for equipment or who verified that the equipment was clean, the chef stated that they did not have a Master Cleaning Schedule but were in the process of creating one. The surveyor observed that outside of the gas oven and fryer were splattered with grease and food particles. The inside glass of the oven door was covered with burnt brown material. The flat top stove was observed with burnt food particles located on the inside and behind the controls of the flat top. The FDS stated that they would have to clean the inside with a vacuum. The surveyor observed an uncovered, unlabeled, undated silver hotel pan full of spice located under a preparation table. The EC identified the spice as a salt and pepper cooking mixture and indicated that it should be covered and labeled with a use by date. Next to the salt and pepper mixture was a large 10-pound bag of dry elbow macaroni covered with plastic wrapping. The macaroni had no opening date or use by date. The Chef indicated that it should be dated when it was opened and a date that indicated how long it was good for. He stated that both the salt and pepper mixture and the dry elbow macaroni would be discarded. The surveyor observed a large 1-gallon container of vegetable oil with no use by date and a 16 oz of box of powdered sugar with a use by date of 08/30/24. The EC indicated that the vegetable oil should be dated, and the powdered sugar needed to be discarded as it was past the used by date. There were 7(seven) three-gallon containers of ice cream located in the ice cream freezer with no opening or use by dates. The FSD stated that he did not date them because they were usually gone within a couple days. The surveyor observed 3 (three) silver hotel pans covered with plastic which contained almonds, walnuts, and pecans with use by dates of 08/29/24. The FSD indicated that the nuts would be discarded as they were past the use by dates. The surveyor observed 1-silver hotel pan covered with plastic which contained ice cream sprinkles with a use by date of 08/29/24. The FDS indicated that the sprinkles would be discarded as they were past the use by date. The surveyor observed a silver hotel pan which contained sliced canned cranberry sauce stored with other toppings used for ice cream. The cranberry sauce was covered with plastic but did not contain a date when opened or a use by date and a 4 (four) pound jar of maraschino cherries with no opening date or used by date. The FSD stated that the cranberry sauce and the cherries would need to be discarded. The surveyor entered the freezer with the FSD and EC and observed 2 (two) large trays of premade turkey meatloaf covered with plastic wrap with a use by date of 08/26/24 and large zip lock bag of scallops with a use by date of 01/13/24. The FSD explained to the surveyor that these items needed to be decarded because they were past the use by date and should not have been in the freezer. On 09/03/24 09:34 AM, the surveyor interviewed the FSD who had been employed in the facility for 1 1/2 year and was a culinary school graduate with an associate degree. The EC indicated that he was also a culinary school graduate. The FSD and the EC both agreed that the items listed should have had use by dates to assure that the food was fresh. The FSD stated that if the items were not stamped with an opening date or a used by date then you would not know how long the food item was good for. The FSD provided the surveyor with the following policies. The facility policy titled, Dry Storage Life of Foods dated January 2023, indicated that the facility used the manufacturers expiration date for product storage. The policy also reflected a list of food items that it if delivered with no expiration dates, the staff were to utilize the policies guidelines for dating and labeling of dry foods. The food item should be labeled with the date that the food was received and discarded when the quality of the product was deemed unacceptable. On 09/06/24 at 12:30 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who reviewed the dry food storage policy with the surveyor. The LNHA admitted that the policy was not specific for the labeling and dating of the dry foods and indicated that the current policy was up for interpretation. She stated that dry food must be labeled with the received date and use by date. The facility policy titled; Frozen Storage Life of Foods dated January 2023, indicated that the facility utilized the expiration date for products however do not exceed 1(one) year. If there was no expiration date on the package the facility was to add the time listed to the date the food was received. In the case of food is partially used and the remaining food was exposed to air relabel the product opened to use within 3-months. The facility policy titled, Cleaning Frequency and Schedules dated 10/01/2022, indicated that contact surfaces shall be cleaned before each use and any time contamination may have occurred. Non-food contact surfaces shall be cleaned at a frequency necessary to prevent the accumulation of soil. The policy also indicated that cleaning task, including procedures must be assigned to appropriate associates in accordance with the usual job or duty performed. The facility was to create the cleaning schedule worksheet, Master Cleaning Schedule and Individual Area Cleaning Schedule sheets for the entire operation that included what needed to be cleaned, who was responsible for cleaning it and when it was to be cleaned. The policy indicated that the facility was to verify cleaning was being done properly and at the correct frequency by signing off the Individual Area Cleaning Schedule. These cleaning worksheets and schedules were to be retained for a period of 30 days. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life specifically by not providing a privacy cover for a urinary catheter drainage bag. The deficient practice was identified for 2 of 2 (Residents # 29, # 31) residents reviewed for Dignity. The deficient practice was evidenced by the following: On 09/03/2024 at 09:24 AM during the initial tour of the facility, the surveyor observed Resident # 29 in bed. At that time, the surveyor observed a urinary catheter drainage bag attached to the bed. There was no privacy cover. There was residual urine visible in the bag. On 09/03/2024 at 09:28 AM during the initial tour of the facility, the surveyor observed Resident # 31 in his/her wheelchair. At that time, the surveyor observed a urinary catheter drainage bag on the side of the wheelchair. There was no privacy cover. On 09/05/2024 at 08:50 AM, the surveyor observed Resident # 31 in his/her wheelchair. At that time, the surveyor observed a urinary catheter drainage bag on the side of the wheelchair. There was no privacy cover. On 09/05/2024 at 08:53 AM, the surveyor observed Resident # 29 in bed. At that time, the surveyor observed a urinary catheter drainage bag attached to the bed. There was no privacy cover. A review of Resident # 29's Physician's Orders located in the Electronic Medical Record (EMR) revealed he/she had an order for catheter care every shift. A review of Resident # 31's Physician's Orders located in the EMR revealed he/she had an order for catheter care twice daily. A review of Resident # 29's Quarterly Minimum Data Set (MDS; An assessment tool) dated 07/17/2024 revealed under section, H that he/she had an indwelling urinary catheter. A review of Resident # 31's Quarterly MDS dated [DATE] revealed under section, H that he/she had an indwelling urinary catheter. On 09/05/2024 during an interview with the Infection Preventionist (IP), the Surveyor asked if residents are in bed who have a urinary catheter, should the drainage bags have a privacy cover. The IP replied, Yes, they should. On the same date at 12:40 PM during an interview with the Licensed Nursing Home Administrator (LNHA), the Surveyor asked should residents with indwelling urinary catheters have privacy covers for the drainage bag. The LNHA replied, Yes. Further, the LNHA stated, Its a dignity issue. It could be a room mate's visitor that is there. Its a dignity issue. A review of the facility policy titled, Quality of Life - Dignity with a revised date of 1/24/24 revealed that, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy also revealed that, 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Lastly, 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident keep urinary catheter bags covered . NJAC S 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On 06/12/2023 at 9:25 AM, the surveyor accompanied by the Food service Director (FSD) observed the following in the kitchen: The surveyor observed a number of unlabeled food items throughout the kitchen such as potatoes, a crate of milk, sugar, bagel, and cheese. The FSD observed at the time of the tour that these items were not labeled and confirmed the items should have been labeled appropriately. The surveyor further observed two items of french toast and french fries that had expiration dates that were dated out for one month. The FSD confirmed the label should only have been dated out for a couple of days and stated the labeling machine must have had a glitch and the FSD would check it to see and make the changes. The surveyor did not observe the french toast nor the french fries get discarded. The surveyor observed a liquid substance on the floor, which appeared to be water coming from the bottom of the refrigerator, that held the sandwiches. This was observed by the FSD as well at the time of the tour. The FSD confirmed it was water and stated he would get maintenance to look at it. During that same day of the kitchen tour at 10:14 AM, the surveyor observed a dining room hostess (DRH) walk into the middle of the kitchen prep area without a hair net on and without stopping to wash their hands. The FSD confirmed that the DRH was not wearing a hair net and should have worn a hair net before entering the kitchen. The FSD confirmed the staff was the DRH who normally cuts through the kitchen to go into the dining room area, but further confirmed with the surveyor, that the DRH should have put on a hairnet before walking into the kitchen. The surveyor interviewed the DRH who stated that they usually wear a hairnet but was looking for their supervisor and apologized for not having one on. The DRH then confirmed with the surveyor that a hairnet was important to be worn in the kitchen at all times. On the second tour of the kitchen, 06/20/23 at 10:05 AM, the FSD confirmed that adjustments were made to the label machine and the labels were correctly placed on the French toast and the French fries. The FSD further confirmed that the french toast and french fries were not discarded, just relabeled. The surveyor observed the dish machine temperatures during the wash cycle and was able to confirm the correct temperature but had difficulty reading the second and third glass coverings. The FSD observed at the time of the tour that the two gauges were hard to read and confirmed the second and third glass coverings should be replaced. The FSD pointed out that the first gauge had already been replaced and the surveyor observed that the first gauge appeared to be new and was clear. The FSD further confirmed that the gauges should be easy to read at a glance to ensure the machine was ran at the correct temperatures without any delays. During that same day of the second kitchen tour, the surveyor observed a facility's System Chef (SC) staff walk into the middle of the kitchen prep area without a hair net on and without stopping to wash their hands. The FSD confirmed that the SC staff usually wears a chef hat and a beard net and should have put on the chef hat and a beard net before entering the kitchen. The surveyor interviewed the SC who stated that they usually wear a chef hat and a beard net but only went into the kitchen to look for the FSD and apologized for not having one on. The SC then confirmed with the surveyor that a chef hat and the beard net was important to be worn in the kitchen at all times to prevent contamination. Review of the facility's policy, Food and Supply Storage, dated for January 2023, revealed that all food, non food items and supplies used in food preparation shall be stored in such a manner to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Under procedures the policy stated to cover, label, and date unused portions and open packages. Review of the policy, Dress Guidelines for Food Service Management and Clinical Nutrition Staff, dated for January 2023, revealed under procedures that hair restraints are worn by all when in the kitchen. This includes department associates, associates from other departments and guests such as vendors.

Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to include the location of a elopement alarm. This deficient practice was identified for 1 of 17 residents reviewed for resident-centered care plans (Resident #6), and was evidenced by the following: On 06/13/23 at 11:40 AM, the surveyor observed Resident #6 in a wheelchair with a wander guard (a device to ensure a resident does not exit the facility) on the right ankle. According to the Admission Record, Resident #6 was admitted with diagnosis that included, but were not limited to, dementia and hypertension. (High blood pressure) A review of Resident #6's annual Minimum Data Set, an assessment tool dated 06/12/23, revealed that he/she had severe cognitive impairment and utilized a wander/elopement alarm daily. A review of Resident #6's Physician Order Sheet reveals an order dated 7/13/22 to check wander guard placement and function to right ankle. A review of Resident #6's Care Plan Report with an effective date of 7/13/22-present reflected that this resident has exit seeking behaviors. One intervention included wander guard to the wheelchair with the status as active/current. On 6/15/23 at 10:22 AM, the Licensed Practical Nurse/ Nurse Manager LPN/NM stated that the wander guards used to be placed on the resident wheelchair, but the team decided to place on the resident instead. She acknowledged that the Care Plan for Resident #6 should have been updated to reflect that this resident has a wander guard on the right ankle. A review of the facility policy Resident Care Plan (RCP) revised 9/11/17 reflects that the effectiveness of the RCP must be regularly evaluated based on progress towards goals. The RCP will be modified as necessary based on the evaluation process. NJAC 8:39-11.2(i)

Based on observation, interview, and record review it was determined that the facility failed to check a resident's wander guard device for functioning for 1 of 2 residents reviewed for wander guards (Resident #41) and was evidenced by the following: On 06/12/23 at 11:10 AM, during the initial tour of the facility, Resident #41 was in the activity room in a wheelchair. The surveyor observed a wander guard (an alarm device to ensure the resident cannot exit the facility) on the resident's left ankle. Review of Resident #41's Face Sheet indicated the resident was admitted to the facility in November 2021. Medical diagnoses included, but were not limited to heart failure, heart disease, dementia, and hypertension (high blood pressure). Review of quarterly Minimum Data Set (MDS), an assessment tool dated 04/11/23 reflected under section P titled, Restraints and Alarms was coded number 2, meaning the alarm was used daily. Review of section C titled, Cognitive Status revealed that Resident #41 had a Brief Interview of Mental Status of 04, meaning the resident had severe cognitive impairment. On 06/13/23 at 11:28 AM, the surveyor observed Resident #41 in the activity room in a wheelchair. The resident had a wander guard to the left ankle which was over his/her sock. On 06/13/23 at 12:03 PM, the surveyor reviewed the physician orders which revealed an order dated 06/06/23 to check placement of the wander guard every shift two times daily, the order did not specify where the wander guard was located on the resident and there was not an order to check for function of the wander guard. On 06/14/23 at 11:26 AM, the surveyor interviewed unit Licensed Practical Nurse (LPN) regarding wander guards. The LPN told the surveyor, We check for placement, make sure there are no skin issues. We make sure there is an order for the wander guard. Its only for those who seek exit, so residents are monitored more closely. I don't know about device checks, I'm agency but we make sure they do work if they go too close to door. On 06/14/23 at 11:26 AM, the surveyor interviewed a unit Registered Nurse (RN) who said that Resident #41 wander guard was checked for placement twice daily (meaning every shift the staff checked to ensure it was on the resident), the surveyor asked who checks for function and the nurse told the surveyor, That's done at night, I am not here at night so I'm not sure where it is documented. The RN referred the surveyor to the Director of Nursing. On 06/14/23 at 11:31 AM, the surveyor interviewed the Director of Nursing (DON) regarding wander guard function documentation. The DON said, It should be in the documented Treatment Administration Record (TAR). The DON asked the unit charge nurse to check for the documentation, in the presence of the DON and surveyor and the charge nurse checked and said, Nope, it's not there. On 06/15/23 at 09:25 AM, the surveyor reviewed Resident #41 current active care plan. The care plan had a focus of Fall/Injury/Elopement Risk and indicated the resident was at risk for leaving the facility unassisted especially during the late afternoon and the evening. One intervention included wearing a wander guard. It was an active care plan. On 06/20/23 at 11:03 AM, the surveyor reviewed the policy titled, Community Elopement Alert/Security System, with a revision date of 3/23/12, under the procedure section of the policy, it indicated that the facility would test resident signaling devices daily and record results. NJAC 8:39-27.1 (a)

Based on observation, interviews, record review and other facility documentation, it was determined that the facility failed to: a) maintain accurate accountability and reconciliation for controlled medications in a medication cart and automated medication dispensing system b) maintain the integrity of emergency medication boxes in a safe manner in accordance with the facility policy. This deficient practice was identified in 1 of 2 medication carts, 1 of 1 automated medication dispensing system, and 2 of 2 emergency medication boxes on 1 of 1 nursing unit. This deficient practice was evidenced by the following: 1. On [DATE] at 12:02 PM, the surveyor inspected the high side medication cart in the presence of the agency Registered Nurse (RN). Review of the Controlled Medication Count Sheet (CMCS) revealed that on [DATE], both the day nurse and the night nurse failed to sign the form in the space provided to confirm that a narcotic count was performed at the end of their shifts to ensure accuracy. Further review of the CMCS revealed that on [DATE], the night nurse failed to sign the CMCS at the end of their shift. The agency RN stated that if blanks were noted on the CMCS it indicated that the responsible nurse forgot to sign the entry after the narcotic count was completed and the Charge Nurse was required to be notified of the missing signature for follow-up. On [DATE] at 1:29 PM, in the presence of the Licensed Nursing Home Administrator (LNHA) the surveyor interviewed the Director of Nursing (DON) who stated that if nursing noted that someone failed to sign the CMCS they were required to report that the book was not signed before they assumed responsibility for the medication cart to assure that the count was right and nothing was missing. The DON further stated that she was not aware of the missing signatures. On [DATE] at at 12:25 PM, the surveyor inspected the automated medication dispensing system in the presence of the DON and Charge Nurse (CN). Review of the Narcotic Count form revealed that the form was not signed on [DATE] or [DATE]. The DON stated that she glanced at the book once a week to see if there were signatures missing. The DON stated that she did not review the narcotic count on Monday [DATE], as it was the first day of survey. The CN and the facility Registered Nurse (RN) inventoried the narcotic count in the presence of the surveyor and there were no discrepancies noted. The surveyor asked the CN if she was aware of the missing signatures and who was responsible to perform the narcotic count. The RN who was present, stated that she worked on both [DATE] and [DATE] and performed the narcotic count with another nurse over the weekend but they both forgot to sign the Narcotic Count form after the count was completed. On [DATE] at 9:12 AM, the DON provided the surveyor with a print out of the automated medication dispensing system audit, which revealed that a narcotic count was not performed on [DATE] or [DATE] as previously described by the facility RN. The DON stated that while both she and the Charge Nurse shared the responsibility of ensuring that the narcotic counts were completed, it was ultimately her responsibility. 2. On [DATE] at 11:37 AM, the surveyor inspected two emergency medication boxes which were both unlocked and stored beneath the front counter of the nurse's station. When the surveyor opened the the first box there were three unused plastic yellow locks stored within the medication box. On the outside of the emergency medication boxes there was an inventory sheet which indicated that the medications contained within the box expired on ,d+[DATE] and ,d+[DATE]. The DON stated that the boxes should have been locked. The DON stated that she noticed that the boxes were unlocked about a month ago and notified the pharmacy at that time to replace them. The DON explained that the boxes were delivered to the facility with a lock already on them. The DON further explained that when nursing accessed the box to remove an emergency medication they were required to notify the pharmacy so that the pharmacy could switch it out with a whole new box. The DON stated that if the pharmacy was not notified then we would not have the required medications in an emergency situation if needed. The DON confirmed that she did not follow-up with nursing to ensure that the emergency medication boxes were replaced. In a later interview with the DON on [DATE] at 12:25 PM, the DON stated that nursing did not have to call the pharmacy for a replacement emergency medication box when the box was accessed and a medication was removed as there were two of most drugs and a second box was available in her office as a back up. The DON stated that when nursing stored both unlocked emergency medication boxes beneath the front counter of the unsecured nurse's station it posed a risk to resident safety. On [DATE] at 12:52 PM, the DON confirmed that an inventory was performed of both emergency medication boxes and she stated that Vitamin K (used as an antidote for blood thinner medication) was missing from the first box and Insta-Glucose (used to treat low blood sugar in diabetics) was missing from the second box. At that time, the surveyor reviewed the Emergency Medication Box List provided by the DON which indicated the following: *Important: Please notify pharmacy immediately upon opening kit for prompt replacement. On [DATE] at 12:58 PM, the surveyor interviewed the Pharmacist who stated that the nurses were required to complete a form with the resident's name when they removed a medication from the emergency medication box and send it to the pharmacy. The Pharmacist stated that the pharmacy then picked up the box the next day and replaced it with another. The Pharmacist stated that there should have been a second box for back up. The Pharmacist stated that he did not keep records to confirm when the facility requested replacement emergency medication boxes. The Pharmacist stated that both emergency medication boxes should have been locked after opening as it was in their policy for security purposes. On [DATE] at 10:59 AM, the surveyor interviewed the CN who stated that when a medication was removed from the emergency medication box a form was sent to pharmacy with a request to replace the entire box. The CN stated that she did not know that either box was opened and unlocked. The CN explained that the unlocked emergency medication boxes could present a danger to residents if they wandered into the nurse's station. Review of the facility's policy, Controlled Substances (Revised [DATE]) revealed the following: Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Review of the facility's policy, Automated back up supply system ([DATE]) revealed the following: Controlled drugs will be inventoried by 2 licensed professionals per facility daily, preferably on the day shift . Review of the pharmacy policy, Emergency Medication Kit ([DATE]) revealed he following: Procedure: Tackle Box Version . Verify that the serial number matches the last serial number entered on the Medication Use Log. If it does not match or the kit is unlocked, (2) nurses must verify contents of the E-Kit. If drugs are missing, and not documented on the Medication Use Log, notify DON ASAP. Remove the required medication from the kit . Complete the pre-printed label on bag. Use as prescription label. Fax to pharmacy a physician's order with Removed from E-kit and the quantity removed noted directly on the order. Completely fill out the Medication Use Log. The pharmacy will send a replacement kit within 72 hours after receiving all appropriate information . NJAC 8:3929.7(C)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to properly store and dispose of controlled medications in accordance with the facility policy and standards of professional practice. This deficient practice was identified for 1 of 2 medication carts on 1 of 1 nursing unit. This deficient practice was evidenced by the following: On 06/14/23 at 12:02 PM, the surveyor inspected the high side medication cart in the presence of the agency Registered Nurse (RN). The RN removed a pill bottle from the locked drawer where controlled substances were stored and identified the medication as Ativan (used to treat anxiety) 0.5 mg. The RN removed two clear sealed plastic bags from the pill bottle which each contained ten tablets. The RN then proceeded to pour five loose tablets into the lid of the pill bottle in order to demonstrate that there were 25 pills in the bottle which corresponded with the Individual Patient's Controlled Drug Record (IPCDR). When the RN began to return the loose tablets to the pill bottle she dropped one of them onto the IPCDR and used a plastic spoon to scoop up the dropped tablet which she returned to the pill bottle with the remainder of medication. At that time, the surveyor asked the RN what the protocol was when a medication was dropped. the RN stated that if she dropped the medication on the floor, or in or on the medication cart which were not considered clean, then she would have wasted the medication with another nurse. The RN stated that the book where the IPCDR was clean, so the Ativan tablet was returned to the pill bottle. The surveyor asked the RN why the Ativan was stored in a pill bottle instead of on a Bingo Card (a method of packaging medications in a blister pack) as the remainder of the controlled substance tablets were stored. The RN explained that since the medication belonged to a resident who resided in the Independent Living (IL) portion of the facility who was admitted for rehabilitation. The RN further explained that the admitting nurse, who was not available for interview, created a declining inventory sheet to account for administration of the resident's own prescription of Ativan. On 06/14/23 at 12:42 PM, the surveyor interviewed the Director of Nursing (DON)who stated that if an Ativan tablet were dropped on the IPCDR it should have been destroyed as it was considered dirty. The DON stated that she was not aware that controlled medications were stored in the medication cart that were not supplied by the facility's pharmacy provider in bingo cards as required. On 06/14/23 at 1:29 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that if the RN dropped an Ativan tablet on top of the IPCDR it was considered contaminated and should have been discarded. On 06/14/23 at 1:48 PM, in a later interview with the agency RN, she stated that when a resident was admitted to the facility from IL with their own controlled substances they were stored in a pill bottle from their own pharmacy and the nurses used blank copies of declining inventory sheets, known as IPCDR, that were created for inventory purposes. The RN explained that on 06/06/23, there were 28 tablets of Ativan when the medication was received and 25 tablets remained. Review of the unsampled resident's Physician's Order Sheet and Medication Administration Record (MAR) revealed that an order was obtained on 06/05/23 for Lorazepam 0.5 mg (1 tablet) oral as needed one time daily for fourteen days for anxiety. On 06/15/23 at 11:27 AM, the surveyor interviewed the DON who stated that the unsampled resident's Ativan prescription was destroyed and a new order was obtained. The DON stated that the unsampled resident's Ativan prescription should not have been accepted by the admitting nurse as the medication was pre-poured and counted by the clinic. Review of the facility's policies, Administering Medications ( revised 02/06/20) and Medications brought to the facility by the Resident/Family (effective 02/01/17) revealed the following: .Appropriate infection control procedures must be followed during the administration of medications . The facility shall ordinarily not permit residents and families to bring medications into the facility. .The facility discourages the use of medications brought in from outside, and will inform residents and families of that policy as well as applicable laws and regulations. NJAC 8:39-29.4(a)(h)(d)

Based on interviews, observation, record review, and review of pertinent facility documentation, it was determined that the facility failed to initiate a care plan for residents receiving anticoagulant medications (blood thinners). This deficient practice was identified for 5 of 17 residents (Resident #6, #7, #12, #26, and #37) reviewed for comprehensive care plans, and was evidenced by the following: 1. On 4/8/21 at 12:33 PM, the surveyor, observed Resident #12 sitting in their room eating lunch. The surveyor attempted to interview the resident but was unable to. The surveyor reviewed the medical record for Resident #12. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility in November of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 1/22/21, indicated in section N for Medications, noted that the resident was administered an anticoagulant medication (blood thinner) for seven of seven days. A review of the April 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's individualized person-centered Care Plan (CP) dated effective 11/19/19 did not include the use of anticoagulant medications. On 4/13/21 at 10:42 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1), who stated that the CP was completed and updated by the Registered Nurses (RN). On 4/13/21 at 11:58 AM, the surveyor observed the resident sitting in their room receiving lunch from the Certified Nursing Aide (CNA). On 4/13/21 at 12:00 PM, the surveyor interviewed LPN #2, who stated that the resident was very forgetful, confused, and depressed. The resident received several medications for his/her heart condition but could not recall if the resident received an anticoagulant medication; The LPN confirmed that she was not involved in the CP process. On 4/13/21 at 2:46 PM, the DON, in the presence of the Executive Director, Infection Preventionist, UM, Regional Nurse Consultant, and survey team, stated that the CP's for anticoagulants have already been addressed and that all resident on anticoagulant medications now have a CP for that medication. The DON confirmed that the residents should have had a CP for anticoagulant medications prior to the surveyor inquiry. 2. On 4/8/21 at 12:30 PM, the surveyor, observed Resident #37 being propelled in their wheelchair by staff to the restroom. The resident was dressed with no observed bruising. The surveyor reviewed the medical record for Resident #37. A review of the Face Sheet reflected that the resident was admitted to the facility in February of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission MDS reflected in section N. Medications that the resident received anticoagulant medication (blood thinner) for four of seven days. A review of the April 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's individualized person-centered CP dated effective 2/22/21 did not include the use of anticoagulant medications. On 4/13/21 at 10:42 AM, the surveyor interviewed LPN #1, who stated that the CP was completed and updated by the RN. On 4/13/21 at 11:14 AM, the surveyor interviewed the DON, who stated that initial CP was completed within twenty-four hours of a resident's admission by the admitting nurse of the UM. The MDS Coordinator then completed the CP based on the comprehensive MDS assessment. The DON stated that the CP, in general, contained plan for any wounds, treatments, certain medications like [CONDITION(S)] (mental health), antidepressant, antianxiety, and anticoagulant use for each individualized resident. On 4/13/21 at 11:24 AM, the surveyor interviewed the MDS Coordinator, who stated that anyone could create or update the CP, and not just her. The baseline CP was completed upon admission by the admitting nurse, which included activities of daily living, cognition, skin condition, dietary, rehabilitation, and medications; anything that was known about the resident upon admission. The comprehensive CP was completed after the MDS was completed. The MDS Coordinator stated that the nurses would need to monitor a resident on an anticoagulant because of the risk factors associated with that medication. The MDS Coordinator confirmed that she does initiate a CP for that. On 4/13/21 at 11:53 AM, the surveyor observed the resident ambulating with a walker in the hallway with therapy. The resident's skin did not appear visibly bruised. On 4/13/21 at 11:54 AM, the surveyor re-interviewed LPN #1, who stated that the resident was on an anticoagulant for congestive heart failure. The resident's skin was monitored for bruising and bleeding, and they denied any current concerns. The LPN stated that she was not involved in the updating or initiating of a CP. On 4/13/21 at 2:46 PM, the DON, in the presence of the Executive Director, Infection Preventionist, UM, Regional Nurse Consultant, and survey team, stated that the CP's for anticoagulants had already been addressed and that all resident on anticoagulant medications now have a CP for that medication. The DON confirmed that the residents should have had a CP for anticoagulant medications prior to the surveyor inquiry. 3. On 4/13/21 at 11:42 AM, the surveyor reviewed Resident #6's Admission Record, which indicated that the resident was admitted in November of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly MDS dated [DATE] revealed that Resident #6's cognition was severely impaired. The MDS also indicated that the resident received an anticoagulant. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS had a start date of 10/22/20 and no end date. The POS also indicated that the medication was ordered for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the same day, during a review of the Resident's medical record, the surveyor reviewed a Care Plan that did not reveal Resident #6 being on an anticoagulant and at risk for bleeding. At 1:16 PM, the surveyor interviewed LPN #2, who stated that Resident #6 takes [MEDICATION(S)] 2.5 mg two times daily. LPN #2 mentioned that the medication was an anticoagulant, and the medication side effects were as follows: bleeding, bruising, and blood clotting. LPN #2 looked in the computer located on top of the medication cart to review Resident #6's Care Plan. LPN #2 confirmed that the Resident did not have a care plan initiated for anticoagulant medication. LPN #2 continued to mention that care plans are created by the Registered Nurse, Supervisor, or Unit Manager. LPN #2 stated the reason for a care plan was to have short-term goals and long-term goals; and that the Resident was non-ambulatory, therefore staff was to observe for bleeding and blood clots. At 1:27 PM, the surveyor interviewed the Unit Manager (UM), who stated that care plans are discussed during the morning meetings and quarterly and consisted of the following staff members: MDS Coordinator, Social Service, Therapy, DON, and Unit Manager. The UM mentioned that Resident #6 did not have a care plan because We don't have a policy for residents on [MEDICATION(S)]. The UM confirmed that [MEDICATION(S)] was an anticoagulant, a high-risk medication, and the resident received it for [CONDITION(S)]. The UM mentioned that staff observed the Resident for medication side effects such as bleeding, dizziness, monitor for falls and nose bleeds. The UM continued to state that the purpose of the care plan was to give direction on the flow of care planned for the resident. On 4/14/21 at 12:26 PM, the UM provided an anticoagulant Care Plan created on 4/14/21, that reflected Resident #6 was at risk for bleeding secondary to the use of an anticoagulant. 4. On 04/07/21 at 10:27 AM, the surveyor, observed Resident #7 sitting in a chair and combing their hair. The resident stated they just had a shower, was not experiencing any pain, and confirmed that they took a blood thinner as part of their daily medication regimen. The top of the resident's hands had minor pink and purple discoloration. On 04/14/21, the surveyor obtained and reviewed medical records for the resident consisting of a Face Sheet, MDS, PO Sheet, and CP. According to the Face Sheet, the resident was admitted to the facility in October of 2020 with various diagnoses, including [CONDITION(S)]. The resident's Quarterly MDS Assessment, dated 01/18/21, revealed that the resident received and an anticoagulant during the previous seven out of seven days, during the review period. Further review of the MDS revealed a BIMS score of 9, which was indicative of moderate impairment as it related to the resident's cognition (thought processes and abilities). The PO Sheet for April 2021 confirmed that the resident had a current order for a blood thinner as [MEDICATION(S)] 2.5 mg, one tablet orally twice per day for [CONDITION(S)]. The interdisciplinary CP through the period of 04/13/21 revealed that there was no plan of care related to the use of the anticoagulant. 5. On 4/8/21 at 7:56 AM, the surveyor observed Resident #26 in bed with the head of the bed elevated. The resident was feeding themselves breakfast without difficulty. At 11:59 AM, Resident #26 was sitting up in a recliner in their room and stated, I'm doing ok. On 4/13/21 at 9:32 AM, the surveyor reviewed the Admission MDS dated [DATE], which indicated in section N. Medications that the resident was administered an anticoagulant medication for one of seven days. At 10:54 AM, Resident #26 was in bed with the head of the bed elevated, and their eyes were closed. A review of Resident #26's medical record revealed an order dated 3/29/21 that read: Hold [MEDICATION(S)] x 24 hours. Diagnosis, epistaxis (bleeding from the nose). The PO sheet for April 2021 confirmed the resident had a current order for a blood thinner as [MEDICATION(S)] 5 mg, one tablet orally two times daily starting on 3/31/21 for DVT Prevention (prevention of a blood clot in a deep vein). On 4/13/21 at 11:27 AM, the surveyor reviewed the facility policy titled Resident Care Plan (RCP) with a revised date of 9/11/17, under Procedure it read: 1. Resident Care Plan will be developed for all care planning issues, including but not limited to: a. Resident Problem b. Resident's goals, incorporate personal and cultural preferences c. Resident's risk factors associated with identified problems d. Resident's needs e. Resident's strengths f. Resident's Functional Status g. Maintenance levels h. Improvement possibilities i. Rehabilitation/Restorative Nursing j. Discharge Potential k. Daily Care Needs 2. The Resident Care Plan will include: a. Problems b. Goals c. Interventions d. Evaluation e. Discharge Plan (when appropriate) On 4/13/21 at 11:14 AM, the surveyor interviewed the Director of Nursing (DON), who stated that initial CP's were completed within twenty-four hours of a resident's admission by the admitting nurse of the Unit Manager (UM). Then the MDS Coordinator completed the CP based on the comprehensive MDS assessment. The DON stated that the CP, in general, contained any wounds, treatments, certain medications like [CONDITION(S)] (mental health), antidepressant, antianxiety, and medications (such as anticoagulant therapy) for each individualized resident. At 11:24 AM, the surveyor interviewed the MDS Coordinator, who stated that anyone could create or update the CP, and not just her. The baseline CP was completed upon admission by the admitting nurse, which included activities of daily living, cognition, skin condition, dietary, rehabilitation, medications; anything that was known about the resident upon admission. The comprehensive CP was completed after the MDS was completed. The MDS Coordinator stated that the nurses would need to monitor a resident on an anticoagulant because of the risk factors associated with that medication. The MDS Coordinator confirmed that she does initiate a CP for that. At 1:32 PM, the surveyor interviewed LPN #1, who stated that Resident #26 was on the blood thinner [MEDICATION(S)] 5 mg two times a day and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/14/21 at 12:27 PM, the UM stated that Resident #26's CP for the Problem: Risk for bleeding secondary to anticoagulation therapy had been created on 4/13/21 after surveyor inquiry. A review of Resident #26's Care Plan Report revealed a CP with the Problem identified: Risk for bleeding secondary to anticoagulation with an effective date: 4/13/21 - Present. N.J.A.C. 8:39 - 27.1(a)

Based on observation, interview, and record review, it was determined that the nurse failed to a.) properly administer the correct dose of medication; and, b.) obtain an order to crush and open medication from the physician. This deficient practice was identified for 1 of 1 nurse observed during the medication pass observation task and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 04/09/21 at 8:18 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medication to Resident #16. The LPN poured a total of seven medications into two different medication cups. The medications poured into the first medication cup consisted of one tablet of [MEDICATION(S)] (a vitamin), one tablet of [MEDICATION(S)] 40 milligrams (mg) (a medication used to treat high cholesterol), one tablet of Vitamin C 500 mg (a supplementary vitamin), and one tablet of [MEDICATION(S)] 50 mg (a medication used to treat pain). [MEDICATION(S)] is considered a controlled substance (a medication with a potential for abuse that must be counted and logged when administered). The medications poured into the second cup consisted of two [MEDICATION(S)] 100 mg capsules (a stool softener) and one tablet of Vitamin B-12 1,000 micrograms (mcg) Extended-Release (a supplementary vitamin). The LPN crushed all the medication in the first cup together, explained this was done for ease of swallowing for the resident and mixed the crushed medication with applesauce. The LPN then took out a capsule of [MEDICATION(S)] (KCl) 10 milliequivalents (mEq) (a supplemental medication used to maintain potassium levels within normal range). Potassium levels must remain within the normal range for the heart to function properly. The surveyor observed the LPN open the capsule of KCl over the first cup of crushed medications mixed with applesauce. Part of the KCl capsule contents fell outside and around the cup of crushed medications onto the medication cart. The LPN cleaned the spilled KCl contents off of the medication cart with a disposable wipe. The LPN stated that they did not know how much of the KCl Resident #16 was getting due to the spilled contents, but this would be noted in the record, and the physician would be notified of the occurrence. The LPN further stated that KCl contents were mixed with the other medications, including a controlled substance medication, and the KCl could not be taken out to start the process all over as a result. During an interview with the LPN on 04/09/21 at 11:52 AM, the LPN again acknowledged that KCl capsule contents fell out during the medication pass, and the Nurse Practitioner (NP) was not advised of this yet. The LPN expressed concern that the resident did not receive the total dose of KCl and did not know how much of the dosage the resident received. When the surveyor asked about the spilled KCl contents, the LPN stated that they could have destroyed all medications, gotten a witness to observe the disposal of the mixed medications, and started the medication pouring process from the beginning. The LPN further stated that they should have gotten a witness for the described purposes but did not do so due to concerns of asking someone else to verify the wasting of [MEDICATION(S)] (a controlled substance) that that individual did not witness. The LPN could not provide details of the facility policy related to crushing, opening, and mixing medications when asked to do so. The surveyor obtained and reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A MAR is a document on which a nurse records all medications administered to a resident. The April 2021 PO Sheet revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a note attached to the KCl indicating that the capsule was opened to empty the contents due to the resident's inability to swallow the capsule, that the resident did not receive the entire contents of the capsule, and the physician would be made aware in order to possibly change the medication to another dosage form. The administration of the KCl itself was recorded on the MAR. The surveyor interviewed members of the facility staff in the presence of the survey team on 04/13/21 at 2:39 PM. The Executive Director (ED), who was acting as the Licensed Nursing Home Administrator ( ED/Acting-LNHA), stated that the [MEDICATION(S)] capsule should have been opened and administered separately from the other medication and the Registered Nurse/Unit Manager (RN/UM) agreed. The ED/Acting-LNHA stated that it would have been easier for the LPN to start the medication process from the beginning if the KCl had been opened separately from the other medication. The RN/Regional Representative (RN/RR) stated a different dosage form might be a better option in the future. On 04/13/21 at 2:41 PM, the surveyor asked the facility staff if there should have been a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/14/21 at 10:31 AM, the surveyor further interviewed facility staff in the presence of the survey team. The Registered Nurse/Infection Preventionist (RN/IP) confirmed that there was no order to open/crush medications for Resident #16. The surveyor then reviewed the facility's policy titled, Administering Medications, with a revised date of 2/6/20, which read under Procedure: 9. The individual administering the medication must ensure that the right medication, the right dosage, the right time, and the right method of administration are verified before the medication is administered. The surveyor then provider the pharmacy's policy, titled PCU018 - Medication Administration and General Guidelines 2020 edition, which read that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It is also necessary to ensure that the correct dose of medication is administered. N.J.A.C. 8:39-29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to: a.) obtain a physician's order (PO) for the administration of oxygen; b.) document the administration of oxygen in the electronic Treatment Administration Record (eTAR); c.) document the changing of oxygen tubing and sterile water in the eTAR, and d.) Care Plan for the administration of oxygen. This deficient practice was identified for 1 of 2 residents reviewed for respiratory care (Resident #97) and was evidenced by the following. On 4/8/21 at 9:09 AM, the surveyor observed Resident #97 laying in bed eating breakfast, which they stated was good. The resident was observed being administered oxygen at two liters per minute (2 lpm) via a nasal cannula (tubing that delivers oxygen via the nares). On 4/8/21 at 12:40 PM, the surveyor observed the resident sitting in a wheelchair in their room with their eyes closed. The resident was not receiving oxygen at this time. The surveyor reviewed the medical record for Resident #97. A review of the Face Sheet (an admission record) reflected that the resident was admitted to the facility in April of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that it was still in progress. A review of the April 2021 Physician Order Sheet did not reflect a Physician Order (PO) for oxygen. A review of the April 2021 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the April 2021 eTAR did not reflect oxygen administration for April. A review of the individualized person-centered Care Plan (CP) had not reflected the use of oxygen. A review of the April 2021 Vital Signs reflected that on 4/3/21, 4/4/21, 4/5/21, 4/6/21, and 4/10/21, Resident #97 had a pulse oximeter measurement device on (used to measure the blood oxygen levels) while receiving oxygen administered at 2-3 lpm via nasal cannula. On 4/12/21 at 12:44 PM, the surveyor observed the resident sitting in their wheelchair in their room being administered oxygen at 2 lpm via nasal cannula. The resident was unable to be interviewed. On 4/13/21 at 8:56 AM, the surveyor observed the resident sitting in the wheelchair in their room. The resident was wearing oxygen tubing. The surveyor continued to review the resident's medical record. A review of the Respiratory Therapy Progress Note dated 4/8/21 indicated no observed signs or symptoms of distress; apply oxygen as needed to maintain an oxygen saturation level (blood oxygen level) greater than 91%. On 4/13/21 at 10:23 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA), who stated that the resident was pleasant but had difficulty hearing. The CNA said that he thought the resident received oxygen as needed. On 4/13/21 at 10:42 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN), who stated that the resident had congestive heart failure (a chronic condition where the heart does not pump blood as well as it should) and received oxygen at 2 lpm continuously via nasal cannula. The LPN stated that the resident had an average oxygen saturation level of 96% and improved respiratory therapy. The LPN said that to administer oxygen, the resident would have a PO and be signed as administered on the eTAR. If the order were for continuous oxygen, then the oxygen would not be signed for on the eTAR. The LPN stated that the oxygen tubing and sterile water were changed weekly on Wednesday nights and that the Registered Nurse (RN) completed the Care Plan. At this time, the surveyor asked the LPN to see the PO for oxygen; The LPN confirmed that there was no PO. On 4/13/21 at 10:51 AM, the night Supervisor/LPN reviewed the resident's medical chart. The night Supervisor/LPN stated that according to the Respiratory Therapy Note on 4/8/21, the resident was supposed to be on oxygen as needed. The night Supervisor/LPN said that she did not see a PO for oxygen, but she needed to check the hospital discharge paperwork. She stated that residents were discharged from the hospital with a list of medications; the receiving nurse entered the medications into the computer and confirmed them with the resident's physician. After that, the PO would be sent to the pharmacy to review for any discrepancies. Then, the nurse would reconcile the medications to ensure all the medications were listed at the correct time and dosage. The night Supervisor/LPN stated that nurses signed every shift on the eTAR for continuous oxygen and when administered for an as-needed order. The oxygen tubing and sterile water were changed every week on Wednesday night. The night Supervisor/LPN stated that the admitting nurse usually started a baseline Care Plan which would include oxygen, and she confirmed the resident did not have it. On 4/13/21 at 11:11 AM, the LPN accompanied by the surveyor took the resident's oxygen saturation level of 98% on oxygen. The LPN confirmed the resident's oxygen was being administered at 1 lpm. The LPN stated that the Respiratory Therapist was just here earlier working with the resident. They must have changed the administration rate from 2 lpm to 1 lpm; she had not reviewed the notes yet. The resident was unable to be interviewed at this time. On 4/13/21 at 11:14 AM, the surveyor interviewed the Director of Nursing (DON), who stated that a PO was needed to administer oxygen and that the nurses signed for the administration of oxygen in the eTAR. The DON said that the Care Plan was started upon admission by the admitting nurse and that oxygen should be included. The DON confirmed that there would need to be accountability and monitoring for oxygen, including an oxygen saturation level, the rate being administered, and oxygen tubing and water changing. On 4/13/21 at 2:34 PM, the DON, in the presence of the Executive Director, Unit Manager, Infection Preventionist/RN, Regional Nursing Consultant, and survey team, stated that she reviewed the resident's hospital discharge record and spoke with the resident's physician. The record indicated that the resident was experiencing some shortness of breath at the hospital. The resident now has a PO for oxygen as needed. The DON confirmed that the resident should have had a PO for the oxygen the entire time at the facility. A review of the facility's Oxygen Therapy policy dated 6/1/01 and revised date 5/18/12 included that oxygen therapy is provided upon the physician's written order. The policy also included documenting maintenance of oxygen flow for continuous oxygen on the eTAR, including tubing changes and changing the sterile water in the humidifier. On 4/13/21 at 11:27 AM, the surveyor reviewed the facility policy titled Resident Care Plan (RCP) with an effective date of 4/1/02 and revised 9/11/17 under Procedure it read: 1. Resident Care Plan will be developed for all care planning issues, including but not limited to: a. Resident Problem b. Resident's goals, incorporate personal and cultural preferences c. Resident's risk factors associated with identified problems d. Resident's needs e. Resident's strengths f. Resident's Functional Status g. Maintenance levels h. Improvement possibilities i. Rehabilitation/Restorative Nursing j. Discharge Potential k. Daily Care Needs 2. The Resident Care Plan will include: a. Problems b. Goals c. Interventions d. Evaluation e. Discharge Plan (when appropriate) N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and record review, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications. The required Federal narcotic acquisition forms (DEA 222 form) were not completed with sufficient detail to enable accurate reconciliation for 6 of 7 forms provided as was evidenced by the following: On 4/14/21 at 12:00 PM, a review of the facility's DEA 222 forms revealed the facility did not record the number of packages of controlled substances received or date the medication was received as instructed to on the reverse of the DEA 222 form. The inaccuracies were as follows: Order Form: # 6572, No date and No quantity received Further review of the forms provided revealed there was an inconsistent pattern in regards to ordering the medication package size versus the number of packages being ordered. This inconsistency was identified on the following order forms: Order Form: # 6570, # 6568, # 2045, # 2048, # 2049, On 04/14/21 at 1:28 PM, the surveyor interviewed the interim Director of Nursing (DON), who stated one of the responsibilities of the DON was to complete the DEA 222 forms. The interim DON acknowledged she had not completed the form as required when receiving narcotic medications and should have filled in the quantity received as well as the date the medication was received. She further stated she was unfamiliar with how to complete the new form, and this was the first time she was completing the form since it had been changed. The interim DON additionally stated when she first started at the facility, and she questioned how the previous DEA Form 222 forms were being completed. She questioned if the facility had reversed the number of packages with the package size on previous forms. She stated on 3/16/21, she called the provider pharmacy and clarified under Part One, column one was the number of Bingo cards, and column two was the number of tablets contained in the Bingo card per the narcotic division of pharmacy. A review of the instructions for submission of the DEA 222 form located on the reverse of the form reveals Part 1. Purchaser Information, 2. Only one item may be entered on a single line. Enter the number of packages, the size of the package, and the name of the item. Part 5. Controlled Substance Receipt 1. The purchaser fills out this section on its copy of the original form. 2. Enter the number of packages received and the date received for each line item. On 4/14/21 at 1:44 PM, the surveyor interviewed the Pharmacist from the facility's provider pharmacy, who confirmed the number of packages is the bingo card. The package size is the number of tablets in the bingo card. On 4/14/21 at 2:34 PM, the Licensed Nursing Home Administrator (LNHA) stated there is no consistency. Both the LNHA and the interim DON acknowledged the facility, the provider pharmacy, and the Medical Director need to come together and formulate a plan going forward to fix the process of ordering narcotic medications on the DEA Form 222. A review of the facility's policy provided titled Nursing policies and procedures [Name redacted] Medication Reconciliation, Receipt of Medications at Facility, with a revised date of 4/20/12 read: A. Match all medications with corresponding records. The policy did not speak to the completion of the DEA 222 form once the medication was received by the pharmacy. N.J.A.C. 8:39-29.7

Based on observation, interview, and record review, it was determined that the facility failed to issue the proper required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for 3 of 3 residents (#26, #31, #297) reviewed for facility change notifications. This deficient practice was evidenced by the following: On 4/9/21 at 9:27 AM, the surveyor reviewed three residents (#26, #31, #297) who were discharged from their Medicare Part A stay with benefit days remaining within the past six months and should have received Beneficiary Notices. Resident #26 was admitted to the facility in February of 2021. The last documented covered day of Medicare Part A service coverage was 4/2/21 from a facility-initiated discharge when benefit days were not exhausted. The facility did not present the resident with the required SNFABN form to notify them of the termination of insurance. Resident #31 was admitted to the facility in February of 2021. The last documented covered day of Medicare Part A service coverage was 4/5/21 from facility initiated discharge when benefit days were not exhausted. The facility did not present the resident with the required SNFABN form to notify them of the termination of insurance. Resident #297 was admitted to the facility in November 2020. The last documented covered day of Medicare Part A service coverage was 12/10/2020 from a facility-initiated discharge when benefit days were not exhausted. The facility did not present the resident with the required SNFABN form to notify them of the termination of insurance. On 4/9/21 at 9:27 AM, the surveyor interviewed the Social Worker (SW), who stated that for Medicare Part A residents discharged from Medicare Part A services, she provided those residents with the Notice of Medicare Non-Coverage (NOMNC) form only to alert residents that their coverage was ending and their right to appeal this decision. The SW stated that she provided the SNFABN form to residents that their Medicare Part B coverage was ending. The SW stated that she was unaware that she needed to provide the SNFABN form to Medicare Part A residents since residents and their representatives were aware of their financial responsibilities and potential liability of payment from the admission packet. On 4/9/21 at 12:33 PM, the Executive Director (ED), in the presence of the Registered Nurse/Infection Preventionist and survey team, stated that typically the SNFABN form was completed on admissions to inform residents and their representatives what Medicare-covered and what their financial responsibility would be. The SW has only been employed at the facility for one year. The ED stated that she was also unaware that the SNFABN form needed to be completed after the facility discharged a resident from Medicare Part A Services with benefits remaining. N.J.A.C. 8:39-5.4 (b)(c)

Based on observations, staff interviews, and review of pertinent documentation, it was determined that facility staff failed to perform hand hygiene between resident rooms during the meal tray delivery. These failures occurred during a COVID-19 pandemic. This deficient practice was evidenced by the following: During a continuous observation of Nurse Aide (NA) #1 on 07/09/2020 at 12:28 PM, the NA assisted a resident with setting up a meal tray in room [ROOM NUMBER], including adjusting the bedside table. NA #1 left the room without washing her hands or using hand sanitizer. NA #1 then went to the meal cart, retrieved a meal tray for the resident in room [ROOM NUMBER]-2 and sat the meal tray on the bedside table, unopened. NA #1 left the room, retrieved a meal tray for the Resident in room [ROOM NUMBER]-1 and sat the tray on the bedside table for the resident. NA #1 positioned the table, opened all of the resident's food and utensils and left the room. NA #1 was called to another room and used a sanitizer wipe at that time. On 07/09/2020 at 12:43 PM, an interview was conducted with NA #1 who stated she was supposed to wash her hands before and after leaving a resident's room and she did not use hand sanitizer while passing the resident trays. NA #1 stated she had no answer for why she did not sanitizer her hands. On 07/09/2020 at 12:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she would expect staff to wash their hands if they were dirty or before and after resident care, but she would not expect staff to sanitize their hands when passing trays between residents that were not on isolation. On 07/09/2020 at 2:43 PM, an interview was conducted with the Administrator, who stated she did not have expectations of staff to wash their hands between setting up meal trays between residents. A review of the facility's Handwashing/Hand Hygiene policy, revised on 07/18/2018, specified to use an alcohol-based hand rub, or alternatively, soap and water for the following situations: After contact with objects .in the immediate vicinity of the resident; Before and after eating or handling food; Before and after assisting a resident with meals. NJAC: 8-39:13.1 (c)

Based on interview and record review, it was determined that the facility failed to consistently respond to issues and concerns presented during the monthly resident council meetings. This deficient practice was evidenced by the following: 1) According to the Resident Council Meeting minutes from (MONTH) 28, (YEAR), several of the residents in attendance stated that they would like the sauce or gravy to be placed in bowls to prevent other food items on the plate from getting soggy. This same complaint was also discussed at the (MONTH) 31, (YEAR) meeting. There was no response from the dietary department or any other administrative staff member regarding this recurrent complaint. 2) According to the Resident Council Meeting minutes from (MONTH) 31, (YEAR), council stated that call bells are not always answered in a timely manner especially during the 3-11 shift. Council also stated that there is too much talking at the nurse's station and that the conversations can get a little loud at times. There was no documented response from any administrative staff regarding this concern. 3) According to the Resident Council Meeting minutes from (MONTH) 31, (YEAR), the council has concerns about not having enough linens, especially towels. There was no documented response from any administrative staff regarding this concern. During the (MONTH) 31, (YEAR) meeting, the council again complained about not having enough linens, especially towels. During the resident council meeting that was conducted by the surveyor on 9/6/18 at 10:30 a.m., the alert and oriented residents in attendance stated that gravies and sauces were not always served separately; the call bells were not always answered timely and: there were not enough towels. One of the residents in attendance on 9/6/18 stated that there was no towel available after washing him/her face earlier that same morning. NJAC 8:39-4.1(a)(35)

Based on observation and interview, it was determined that the facility failed to implement a grievance procedure, identify a grievance officer and make this information available to residents. This deficient practice was evidenced by the following: During the Resident Council meeting that was conducted by the surveyor on 9/6/18 at 10:30 a.m., the eleven residents in attendance, including the President of the Resident Council, stated that the facility did not respond to all of their group or individual complaints, issues and grievances. The residents stated that they did not know if the facility had a procedure, including a specific form, for filing grievances that were generated from the Resident Council meetings or that were generated by individual residents. The residents also stated that they did not know if there was a grievance officer assigned to assist them. When interviewed by the surveyor on 9/6/18 at 12:14 p.m., the Social Worker (SW) stated that she was in charge of handling the grievances for the residents. She stated that residents could file a grievance with her. When asked how residents would file the grievance, the SW stated that the residents would use a concern form to document their complaints and give it to the SW. When interviewed, the SW stated that she had never received a concern form from any resident. When asked where the concern forms were located, the SW led the surveyor to a plastic file bin that was attached high on a wall, behind the nurses station. When interviewed by the surveyor on 9/10/18 at 8:40 a.m., Resident #11 stated that the administration handed out a copy of a grievance form and a letter, dated 9/9/18, advising the residents on where the forms are located and how the grievance can be filed but did not identify the Grievance Officer for the facility. When interviewed on 9/10/18 at 10:43 a.m., the Administrator (LNHA) stated that there was a grievance policy however, it was not followed. According to the policy titled, Grievance/Complaints, filing, the residents could file a grievance in writing or orally and could be filed anonymously. The Grievance Officer was identified as the facility's SW. The policy also indicated that the grievance policy was posted on the the residents' bulletin board and the Resident handbook and the forms could be found in the main dining room of the facility. The LNHA stated that the location of the policy and the forms were added to the policy on 9/9/18. NJAC 8:39-4.1(a)(35)

Based on observation, interview and record review, it was determined that the facility failed to ensure that there was sufficient staff to meet the care needs of the residents. This deficient practice occurred to 1 of 11 alert and oriented residents who attended the Resident Council meeting and was evidenced by the following: During the Resident Council meeting that was conducted by the surveyor on 9/6/18 at 10:30 a.m., seven of the eleven residents in attendance stated that they feel like there are not enough CNAs and that the CNAs have too many people on their assignments which makes them very busy. The residents stated that this resulted in the residents waiting up to one hour for the staff on the 3:00 p.m. to 11:00 p.m. and the 11:00 p.m. to 7:00 a.m. to answer their call lights. The residents stated that they have clocks in their rooms where they can time how long it takes for the CNAs to respond to their call lights. These residents also stated that the CNAs tell them that they are understaffed and receive a low pay. Resident #11, who was one of the seven residents who complained of the lack of sufficient staff at the resident council meeting, stated that if there are only three CNAs working on the 3:00 p.m. to 11:00 p.m. shift, the residents do not get their showers. When interviewed by the surveyor on 9/7/18 at 10:45 a.m., two CNAs stated that showers are not given to the residents on the 3:00 p.m. to 11:00 p.m. shift if there are only three CNAs working. When interviewed by the surveyor on 9/7/18 at 10:54 a.m., the Charge Nurses stated that the CNAs are supposed to tell the nurses if a shower was not given to residents on the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 p.m. shifts. When interviewed by the surveyor on 9/10/18, the Administrator stated that the staffing levels are determined by the acuities of the residents. A review of the facility assessment revealed only the total number of nursing staff, including CNAs, that were employed by the facility. NJAC 8:39-27.1

Based on interview, it was determined that the facility failed to address all residents in a manner that maintained their self esteem and self worth. This deficient practice included alert and oriented residents who attended the resident council meeting and was evidenced by the following: 1) During the Resident Council meeting that was conducted by the surveyor on 9/6/18 at 10:30 a.m., four of the eleven alert and oriented residents in attendance stated that there were Certified Nursing Assistants (CNA) who work on the 3:00 p.m. to 11:00 p.m. shift that did not allow the residents to have a say in how their care was provided. The four residents stated that those CNAs, including ones that were employees of the facility as well as contracted agency staff, would respond I'm doing it my way when the residents attempt to inform them of how they want their care and services provided. 2) Three of the eleven alert and oriented residents in attendance stated that they required assistance to use the bathroom. When they put on their call lights, some CNAs respond that they have to wait a minute before the CNAs can assist them with toileting. The residents stated that by the time the CNAs are done talking to the residents about having to wait, they could have have assisted them into the bathroom and on to the toilet. 3) Nine of the eleven residents in attendance stated that the staff speak loudly to each other. The residents stated that this occurs at night at the nurses station, in the hallway, in the dining room during meals and during the residents' activities. The residents added that the staff talk loudly to each other while in the residents' rooms during the provision of care. 4) One of the eleven residents in attendance stated that a CNA made grunting sounds as she pushed the resident down the hallway in a wheelchair. The resident stated that she felt embarrassed by the CNA's behavior. 5) Seven of the eleven residents in attendance stated that there was another resident, in a wheelchair, who wanders into their rooms. These residents added that the resident goes in and out of everyone's room and that no one stops this resident. The resident stated that the resident who wanders into their rooms touches them and 'touches their stuff. One of the seven residents stated that the resident who wanders came into his/her room, grabbed an item off of the table and broke it. This resident stated that he/she had made the item during a craft activity. Another of the eleven residents stated that he/she awoke and found the wandering resident next to his/her bed. The eleven residents stated that this wandering resident frightens and scares them. These residents stated that the wandering resident made them feel unsafe. NJAC 8:39-4.1(a)(12)

Based on observation, interview and record review, it was determined that the facility failed to ensure that all cognitively impaired residents with behaviors were adequately monitored so the behaviors do not impact other residents. This deficient practice occurred to 3 of 23 residents (Residents #11, #16 and #29) who were reviewed during the survey and was evidenced by the following: Seven of the eleven residents in attendance stated that Resident #29, who uses a wheelchair, wanders into their rooms uninvited. These residents added that Resident #29 goes in and out of everyone's room and that no one stops this resident. The residents stated that Resident #29 wanders into their rooms and touches them and 'touches their stuff. One of the seven residents, Resident #16 stated that the Resident #29 came into his/her room, grabbed an item off of the table and broke it. Resident #16 stated that he/she had made the item during a craft activity. Another of the eleven residents, Resident #11, stated that he/she awoke and found the wandering resident next to his/her bed. Resident #11 also stated that on the previous week, Resident #29 wandered into his/her room and blocked the doorway of the room. Resident #11 had to yell for someone to come to the room to escort Resident #29 out of the room. The eleven residents, including Residents #11 and #16, stated that the staff do not watch Resident #29. The eleven residents stated that Resident #29 frightens and scares them. These residents stated that Resident #29 made them feel unsafe. According to to a nurses note, dated 9/5/18, Resident #29 continued to wander in his/her wheelchair and that 1:1 along with redirection, snacks and fluids. According to the plan of care, Resident #29 was constantly in and out of other residents' rooms. The interventions to be implemented for this behavior included one to one therapy as well as snacks, music and comfort items. On 9/5/18 at 9:08 a.m., the surveyor observed that Resident #29 was seated in a low wheelchair, with his/her eyes closed. When interviewed by the surveyor on 9/6/18 at 1:17 p.m., a Certified Nursing Assistant (CNA) stated that Resident #29, who was cognitively impaired, wanders into other residents' rooms and these residents complain. The CNA stated that it was everyone's job to redirect Resident #29 but it was hard to redirect this resident. When the surveyor asked this CNA if Resident #29 was provided with one to one (1:1) supervision, this CNA laughed and stated that we don't have enough staff for that. When interviewed by the surveyor on 9/10/18 at 11:21 a.m., the Director of Nurses (DON) stated that Resident #29 will have a CNA with him at times as an intervention but there was no staff assigned to be 1:1 with the resident. The DON stated that, although the staff should be documenting when Resident #29 wanders into other residents' rooms, the surveyor will not find documentation of this being done. The DON stated that we just keep a watch on Resident #29. Although Resident #11 had told the surveyor that Resident #29 had wandered into his/her room about a week prior and that he/she had to yell to get someone to remove the resident, the DON stated that Resident #29 has had a recent decline and had not wandered into another residents' room in three weeks. NJAC 8:39-27.1

A. Based on observation, interview and medical record review, it was determined that the facility failed to identify and revise care plan interventions to manage the behavior of a resident who a.) wandered consistently and repetitively in and out of residents rooms, taking their belongings and defecating and urinating in public areas, and b.) exhibited difficult to redirect behavior that was unpredictable and included verbal and physical intimidation of residents and staff. Care Plan interventions for the resident's behavior were standardized in nature and lacked a specific plan for increased supervision, identified behavior triggers and emphasis on protecting Resident #8 and other residents in the facility. Failure to identify, facilitate and revise interventions to manage Resident#8's behavior resulted in an Immediate Jeopardy situation. The Immediate Jeopardy was identified on 10/17/12 during the survey and a plan of correction was submitted by the facility and corrected on 10/17/12, by providing 1:1 supervision and developing and implementing interventions to manage the resident's behavior. This deficient practice was identified for 1 of 10 residents (Resident #8) reviewed for behavior symptoms and care plan interventions. This resident, according to the medical record, had multiple incidents of maladaptive behavior. This deficient practice was evidenced by the following: The surveyor reviewed the medical record of Resident #8 on 10/17/12 at 11:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Review of the medical record revealed that since January 2012 to present, the resident had exhibited multiple behaviors that included unsupervised wandering in other residents rooms, taking their belongings, verbal and physical altercations with staff and urinating and defecating in public areas. Review of the Care Plan on the above date and time, revealed that on 7/6/11, the resident was identified as "in and out of activities and often taking others possessions on her way." Interventions at that time included; "1. All staff gently encourage and escort the resident back to activities, 2. Praise (resident) for efforts throughout activity, 3. Try 1:1 during activity where appropriate so as not to single her out, 4. Provide busy things, boxes with lots of stuff." On 6/1/12 a new Care Plan was developed for Resident #8, which again identified that the resident "has been going in and out of residents rooms taking items. She is difficult to redirect will only stay in activity for 10 minutes. She is also starting to get aggressive with residents when asked to leave their room and also with residents in common areas. Interventions included "1. Place a basket of items at nurses station. 2. Place a basket of items in D.R. for collection. 3. Place a basket in activity room for collection. 4. Provide with a collection bag. 5. Staff will redirect (resident) to collection areas and when bag is full redirect (resident) to look in the bag." Review of the resident's current care plan prior to facility notification of the Immediate Jeopardy, revealed the problem identified that "(Resident) is combative with episodes of hitting others, yelling, defecating in public areas and hard to redirect related to dementia with behavioral disturbance." Interventions included to "Encourage (resident) to attend daily activities, physical games, music, busy hands." A list of all of the Resident's current [MEDICAL CONDITION] medications were listed as interventions on the care plan. Interventions also included to "Assess (resident) for physical factors that may be a factor in her behavior, such as hunger, thirst or incontinence, and approach in a calm manner." There was no documented evidence that the resident's behavior of urinating and defecating in public areas was addressed, nor was there any mention of a toileting plan. Interventions also included "(Resident) wanders to the point of exhaustion with periods of elopement." "Redirect the resident if found in other resident's rooms and to provide 1:1 when (resident ) is agitated." On 10/17/12 at 3:00 p.m., the Director of Nurses' (DON) and Social Worker told the surveyor "We do the best we can to keep an eye on her. We do not have the staff to provide 1:1 for residents." The DON was unable to tell the surveyor how increased supervision was being provided for the resident when the companion was not there. "We just redirect her as needed." The DON further stated that inservice training as per the S-Cope recommendation of 9/24/12 had not yet been conducted, and that an inservice to address behavior of dementia residents was scheduled for 10/28/12. That same day at 3:30 p.m., the Administrator told the surveyor "We do not provide 1:1 supervision in the facility. We do not have the staff for it." The Immediate Jeopardy was identified on 10/17/12 at 4:45 p.m. An acceptable Plan of Correction was received on 10/17/12 at 7:15 p.m. and indicated that the jeopardy was corrected on 10/17/12, with specific action that included; Criteria#1 The facility placed a 1:1 care giver with Resident #8 at 3 p.m. Private Duty aides were obtained as of 6:30 p.m. on 10/17/12, to ensure 24 hour supervision for the resident and to prevent disruption to other residents. All aides will be in-serviced by the Director of Nurses' or designee along with the Activities professional staff. Training will be provided regarding interventions. If a private duty aide is not available the Nursing Supervisor will instruct facility staff in providing 1:1 on an hourly basis. The resident's care plan has been up-dated to reflect targeted behaviors and interventions. A 30 day notice of discharge will be served to the family, immediately. Assistance with placement will continue to be provided to support family. Criteria #2 A meeting will be scheduled for October 18 to include all residents who participated in the Resident Council meeting to discuss how the resident has affected them. Criteria #3 The Interdisciplinary Care Plan team will review quarterly or as necessary all residents with behavioral problems for indications of escalating behaviors for adverse effects on other residents. A specific Behavior Care Plan will be developed based on assessment of individual resident activity preferences for any future residents with problematic behaviors. Criteria #4 The Interdisciplinary Care Plan team will review quarterly or as necessary all residents with behavioral problems for indications of escalating behaviors for adverse effects on other residents to determine if interventions are effective. Refer to F 323 Part A F279 remains a deficiency at a scope and severity of D, based on the following evidence in Part B: B. Based on observation, interview and record review, it was determined that the facility failed to revise care plan interventions for a resident who sustained falls related to positioning in the wheelchair. This deficient practice was identified for 1 of 7 residents (Resident #10) reviewed for falls and accidents as evidenced by the following: 2. During the initial tour of the facility on 10/15/12 at 9:25 a.m., the Social Worker (SW) told the surveyor that Resident #10 was very confused, on hospice, and used a wheelchair for mobility; which the resident could self propel. The SW also stated that the resident had chair and bed alarms, and "may have had a fall." The surveyor reviewed the medical record of Resident #10 on 10/17/12 at 11:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The Unit Manager (UM) told the surveyor on 10/17/12 at 11:15 a.m., that the resident had two recent falls. Resident #10 had a fall on 8/4/12 at 8:15 a.m. According to the Occurrence Report provided by the facility, the resident's alarm was sounding and he/she was found lying on the floor in her/his room in front of the wheelchair. The resident was unable to tell nurse how she/he fell . The resident sustained [REDACTED]. The conclusion stated on the Occurrence Report that "staff instructed to assist patient with transfers and toileting." Review of the Care Plan (CP) revealed that falls were identified. The interventions included to check alarms for function, engage resident in activities that improve strength, balance and posture, keep area clear of clutter, and keep call light in easy reach. The fall which occurred on 8/4/12 was identified on the CP, but interventions were not revised after the fall. On 9/19/12 at 1:45 p.m., Resident #10 sustained another fall. The Occurrence Report provided by the facility stated that a Certified Nursing Assistant (CNA) witnessed the resident leaning forward in her wheelchair and the CNA rushed to help, but the resident had already fallen. The resident sustained [REDACTED]. The Occurrence Report did not provide a conclusion or any recommendations. Again, the fall was identified on the CP, but there was no revision of interventions. Refer to F 323 Part B. NJAC 8:39-11.2 (e)2

A. Based on observation, interview and record review, it was determined that the facility failed to adequately monitor and supervise a cognitively impaired resident who was identified with unpredictable behaviors of wandering throughout the unit, verbal and physical mistreatment of [REDACTED]. The incidents were documented in the medical record from 1/2012 to the present and interventions were not revised to protect both the identified resident and residents residing on the unit. The incidents documented in the medical record included, but were not limited to; consistent notations of wandering in and out of residents rooms and confiscating their belongings, defecating and urinating in resident rooms and common areas, and at least 4 documented incidents of physical and verbal altercations with other residents. This deficient practice was identified for 1 of 10 residents reviewed for behavior symptoms, Resident #8, who had multiple incidents of maladaptive behavior that impacted on the health and safety of residents in the facility. This deficient practice constituted an Immediate Jeopardy situation for Resident #8, as well as residents who resided in the facility. The Immediate Jeopardy was identified on 10/17/12. An acceptable plan of correction was submitted on 10/17/12, identifying that the jeopardy situation was corrected on that date based upon actions taken by the facility, which included assigning a 1:1 care giver to ensure 24 hour supervision, education of staff to manage the resident's behavior, and the revision of care plan interventions. The following evidenced the deficient practice: 1. The surveyor observed Resident #8 on 10/15/12 at 11:40 a.m., ambulating in the hall with a walker. The resident had a companion accompanying him/her, who told the surveyor that she was hired by the family to provide increased supervision for the resident. The companion stated that she worked Monday through Friday, from 8:30 a.m. to 2:00 p.m. On 10/17/12 at 10:00 a.m., the surveyor conducted a meeting with 7 alert and oriented residents. Seven of seven residents told the surveyor about a resident that they identified by name as Resident #8, who consistently and repetitively wandered in and out of their rooms and took their belongings. The residents also stated that Resident #8 urinated and defecated in their rooms and public areas. The residents stated that if they told the resident to leave their room, he/she would get angry, yell and try to hit them. The residents stated that staff were aware of the resident's behavior and would, at times, try to re-direct him/her. The seven residents said "we shouldn't have to live like this." On 10/17/12 at 11:00 a.m., the surveyor reviewed the medical record of Resident #8, which revealed that the resident had [DIAGNOSES REDACTED]. Review of Monthly Psychotropic Summary notes from 1/2012 to 10/2012, included notations of the resident's behavior. Examples included, but were not limited to the following: 1/11/12 "Resident continues to take things from all over the facility. She was found with garbage bag and items in it taken out and put on dining room table. Resident became very angry when stuff was taken from her." A total of 13 documented behaviors were identified in the summary notes for the month of January 2012. 2/1/12 "Resident yelling out loud this morning when she was redirected away from pulling soiled pull-ups out of the garbage. Resident continues to take things from other people and wander through the facility continuously." 2/3/12 "Continues to wander the unit, no crying, picks up items along the way and stuffs them in her clothes." 2/8/12 "Resident continues to wander through facility, in and out of peoples room. When trying to redirect resident, she began yelling at the top of her lungs uncontrollably. Difficult to redirect." A total of 8 behaviors were documented in the summary notes for the month of February 2012. 3/20/12 "Resident c/o discomfort in peri area. CNA assisted her to bathroom, she had gloves in her brief and became agitated with staff when attempted to remove them." A total of 3 behaviors were documented in the summary notes for the month of March 2012. 4/28/12 "Resident sat on mattress on floor next to room mate and had a large BM on matt. Resident combative with care." A total of 3 behaviors were documented in the summary notes for the month of April 2012. On 5/1/12, a lab report indicated that the resident was positive for[DIAGNOSES REDACTED]icile, an infectious highly contagious bacteria in the stool. There was no documented evidence that the resident was on any infectious disease precautions at that time, as his/her behaviors continued. 5/20/12 "Hitting staff, throwing soiled items at staff. Numerous attempts made before staff finally able to assist resident." A total of 7 behaviors were documented in the summary notes for the month of May 2012. 6/20/12 "Resident wandering around facility going from one bed to the other. When told that it isn't her bed, becomes agitated. Resident was screaming during p.m. care at CNA." 6/23/12 "Resident wandering about all day in and out of other residents rooms, taking their belongings, becomes angry and agitated at staff." 6/25/12 "Resident continues to wander around the unit, in and out of other residents rooms taking their belongings, causing many of them to yell at her. She yells back, causing a scene and elevating the situation." A total of 6 behaviors were documented in the summary notes for the month of June 2012. 7/1/12 "Resident becoming increasingly agitated when staff attempts to intervene and redirect her from taking other residents things." On 7/12/12 at 12:02 a.m., a nurses' note indicated "Resident c/o her vagina burning, very irritated and reddened. During a.m. care, staff found a sock stuffed in the resident's brief/vagina. Resident very resistive and states "It's burning!" When interviewed on 10/17/12 at 2:00 p.m., regarding this incident, the Director of Nurses' was unable to provide any evidence of a followup in the form of an investigation, or evidence that the physician was notified; or any medical attention was provided. 7/13/12 "Pt. observed going into garbage cans in hallway and on med carts and taking garbage out. Difficult to redirect." 7/15/12 "Resident hit CNA during AM care. Also slapped another resident in the face this morning. Was arguing with residents in the dining room." 7/16/12 "Wandering from room to room digging into garbage and dirty linen. Removed garbage from isolation bin in her room and piled it up on the windowsill. Becomes very agitated with staff when they intervene raising her voice and screaming, slamming down her walker." A total of 12 behaviors were documented in the summary notes for the month of July 2012. 8/2/12 "Resident punched CNA in the arm, also pushed her walker into aides body in an angry manner. Ambulating ad lib in and out of other residents rooms taking their belongings even broke some of them. Attempts to redirect her cause agitation." 8/10/12 "Resident was observed defecating in various public areas including the dining room. She also pulled the cover off the fire alarm but was stopped by staff before she actually pulled the fire alarm." 8/11/12 "Resident wandering in all rooms taking whatever she wants, also digging through garbage and tossing garbage on the floor. Becomes angry and agitated when staff intervene." 8/12/12 "Resident removing items from desk and med cart, when staff approached her she raised her hand and said "I will hit you honey, just you try!" 8/15/12 "Resident ambulating through facility taking things from all over the facility. In early a.m. she was noted by 7p-7a agency nurse laying and playing with a bed full of feces and urine. Resident was also found with garbage soiled with drainage filled dressings." "Explained to resident numerous times about staying out of garbage. Resident is non-compliant." On 8/17/12, a nurses' note indicated "Entering other residents rooms and removing linens then urinating on the stripped bed. Became angry and aggressive toward staff when they attempt to redirect." 8/18/12 "Resident was going in other residents rooms, she was in the dining room for lunch and was interupting other residents so the CNA attempted to redirect her and was slapped on the side of the face." A total of 9 behaviors were documented in the summary notes for the month of August 2012. 9/9/12 "Verbal threats of physical harm to staff if they attempt to stop her from getting into other residents belongings." 9/15/12 "Resident was in dayroom when she approached another resident and threw garland in her face. She also took the cover off of the air/heater unit which was later found. She continues to walk in and out other residents rooms taking things that do not belong to her." 9/16/12 "Pt. entered into Room 132 and preceded to have a BM on the chair in 132 A. Pt. difficult to re-direct." 9/21/12 "Staff observed resident going to other resident breakfast trays and eating from them after finishing her own breakfast." 9/25/12 11:40 a.m. "Struck walker into another resident's wheel chair. Redirected however (resident) became agitated." 9/30/12 "Resident tried to elope out of rear doors. This nurse tried to redirect resident; became agitated and stated "I will fix you!" Lifted walker and continued to slam on ground and come towards this nurse. Continued to be aggressive towards this nurse but redirected by CNA." A total of 20 behaviors were documented in the summary notes for the month of September 2012. Review of an Interdisciplinary Plan Note, dated 10/4/12, revealed the following: "She continues to display behaviors wandering in and out of peoples rooms, picking up other peoples belongings, hoarding, putting items in her bra and down her pants and defecating in public areas. She is not always easily redirected and can be physically and verbally aggressive. "(Resident) family hired an aide which is a companion 3 days wk/3 hrs day as intervention to keep her occupied." "Family is looking into transferring her to dementia unit." Further review of the medical record revealed a Clinical Consultation by S-Cope dated 9/24/12. Recommendations included the following: 1.) "Allow psychotropic medications to be effective." 2.) "Test stool sample for[DIAGNOSES REDACTED] or other infection." 3.) "Have client wear one piece overalls/jumpsuit to decrease her ability to remove diaper and defecate in public." 4.) "Offer facility staff training on managing difficult behavior assoc. with Dementia." 5.) "Client would benefit from placement on a secure dementia unit where she could wander safely." On 10/17/12 at 2:30 p.m., the unit manager told the surveyor that the staff attempt to supervise the resident by keeping her at the desk with them when possible and providing the resident with random items to play with. The unit manager stated "She has a very short attention span, and the items don't occupy her for very long." The unit manager also stated that the resident was on a "toileting program," to manage his/her behavior. There was no documented evidence in the medical record that the resident had been assessed for a toileting plan or that one was in progress, to manage the resident's behavior of defecating in public areas. The care plan also lacked interventions to address the behavior. Review of the CMS Form 672, filled out by the facility, dated 10/16/12, indicated under F98, "0" On individually written bladder training program, and F99, "0" On individually written bowel training program. On 10/17/12 at 3:00 p.m., the Director of Nurses' and Social Worker told the surveyor "We do the best we can to keep an eye on her. We do not have the staff to provide 1:1 for residents." The DON was unable to tell the surveyor how increased supervision was being provided for the resident when the companion was not there. "We just redirect her as needed." The DON further stated that inservice training as per the S-Cope recommendation of 9/24/12 had not yet been conducted, and that an inservice to address behavior of dementia residents was scheduled for 10/28/12. That same day at 3:30 p.m., the Administrator told the surveyor "We do not provide 1:1 supervision in the facility. We do not have the staff for it." The facility policy titled Abuse (Resident Abuse) dated 2/15/01 and revised on 7/7/05 included; ...." to maintain a living enviornment that is free from threats, abuse (physical, verbal, mental or sexual), and neglect..." There is no documented evidence this policy was consistently followed. The Immediate Jeopardy was identified on 10/17/12 at 4:45 p.m. Facility Administration was notified and a plan of Correction was submitted to the survey team and accepted on 10/17/12 at 7:15 p.m., which indicated that the jeopardy was corrected on 10/17/12, based on actions by the facility which included the following: Criteria#1 The facility placed a 1:1 care giver with Resident #8 at 3 p.m. Private Duty aides were obtained as of 6:30 p.m. on 10/17/12, to ensure 24 hour supervision for the resident and to prevent disruption to other residents. All aides will be in-serviced by the Director of Nurses' or designee along with the Activities professional staff. Training will be provided regarding interventions. If a private duty aide is not available the Nursing Supervisor will instruct facility staff in providing 1:1 on an hourly basis. The resident's care plan has been up-dated to reflect targeted behaviors and interventions. A 30 day notice of discharge will be served to the family, immediately. Assistance with placement will continue to be provided to support family. Criteria #2 A meeting will be scheduled for October 18 to include all residents who participated in the Resident Council meeting to discuss how the resident has affected them. Criteria #3 The Interdisciplinary Care Plan team will review quarterly or as necessary all residents with behavioral problems for indications of escalating behaviors for adverse effects on other residents. A specific Behavior Care Plan will be developed based on assessment of individual resident activity preferences for any future residents with problematic behaviors. Criteria #4 The Interdisciplinary Care Plan team will review quarterly or as necessary all residents with behavioral problems for indications of escalating behaviors for adverse effects on other residents to determine if interventions are effective. F323 remains a deficiency at a scope and severity of E, based on the evidence in Part B. Part B. Based on observation, interview and record review, it was determined that the facility failed to a.) determine causal factors of resident falls to develop and revise appropriate interventions and b.) develop a system to ensure safety and consistent application of alarms and safety devices. This deficient practice was identified for 2 of 7 residents reviewed for falls and accidents, Resident #6 and #10, as evidenced by the following: 2. During the initial tour of the facility on 10/15/12 at 9:25 a.m., the social worker told the surveyor that the resident was very confused, was on hospice, and used a wheelchair for mobility, which the resident could self propel. The social worker also stated the resident had chair and bed alarms, and "may have had a fall." The surveyor reviewed the medical record of Resident # 10 on 10/17/12 at 11:00 a.m., which revealed the resident had [DIAGNOSES REDACTED]. The Unit Manager (UM) told the surveyor on 10/17/12 at 11:15 a.m., that the resident had two recent falls. The surveyor observed the resident on 10/17/12 at 11:30 a.m., self propelling around the unit in his/her wheelchair. Review of nurses notes revealed that Resident #10 had a fall on 8/4/12 at 8:15 p.m. According to the Occurrence Report provided by the facility, the resident's alarm was sounding and he/she was found lying on the floor in her/his room, in front of the wheelchair. The resident was unable to tell nurse how she/he fell . The resident sustained [REDACTED]. The conclusion stated on the Occurrence Report was "staff instructed to assist patient with transfers and toileting." Review of the care plan (CP) at that time revealed that the resident was at risk for falls. The interventions included to check alarms to ensure that they were functioning properly, engage resident in activities that improve strength, balance and posture, keep area clear of clutter, and keep call light in easy reach. The fall which occurred on 8/4/12 was identified on the CP, but there was no revision of interventions at that time. On 9/19/12 at 1:45 p.m., Resident #10 sustained another fall. According to the Occurrence Report provided by the facility, a Certified Nursing Assistant (CNA) witnessed the resident leaning forward in his/her wheelchair. The CNA rushed to help, but the resident had already fallen. The resident sustained [REDACTED]. The Occurrence Report did not provide a conclusion or any recommendations. There was no documented evidence of recommendations for remedial action. There was no evidence that physical therapy was included as part of the interdisciplinary approach to assess the residents positioning, after the two falls had occurred from the resident leaning forward. On 10/18/12 at 11:00a.m., the Physical Therapy (PT) Program Manager stated that there had been no PT consults for Resident #10 from 8/1/12 to the present. 3. The surveyor reviewed the clinical record of Resident #6 on 10/15/12 at 12:00 p.m. which revealed that the resident had [DIAGNOSES REDACTED]. Further review of a Fall Risk Assessment revealed that the resident was at high risk for falls on 8/26/11 and 9/6/12. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #6 had short and long term memories deficits. The Interdisciplinary Progress Notes (IDCPN) indicated that Resident #6 had a decline in cognition related to Alzheimer's disease progression. A review of the Resident Assessment Protocol Summaries (RAPS) dated 9/13/12 revealed that Resident #6 triggered for falls. Review of the Care Plan dated 5/29/08 and revised on 9/13/12 identified the problem of "At risk for falls due to poor safety awareness and had poor insight R/T (related to) dementia." The care plan indicated a revised intervention on 12/01/10 with the addition of "floor mat alarm." Other interventions included, bed and chair alarm, bed in lowest position with heels locked. A review of the Incident/Accident Report provided by the facility on 9/13/11 at 1:00 a.m., revealed Resident #6 had an unwitnessed fall. The Incident/Accident Report indicated, " CNA (Certified Nursing Assistant) heard calling out for help, found kneeling on the floor at bedside R(right) face resting on night stand. 2 of 1 cm (centimeter) diameter abrasion noted on R (right) face." Under the section of "Additional comments and/or steps taken to prevent recurrence" revealed "Bed alarm and floor alarm are to be on when resident in bed." Review of the CNA's statement on the investigation report revealed "I heard resident calling for help, so I went to the room and found her kneeling on the floor .....but I noticed her bed alarm did not goes off. " The statement by the nurse revealed, " I spoke with CNA why bed /wall/floor mat alarms were not sounding, and he stated that he was busy and unable to check." Reported matter to night shift supervisor. On 10/18/12 at 9:50 a.m., the Unit Manager Nurse (UMN ) told the surveyor that the alarms were checked daily by the supervisor on every shift. The UMN could not provide any documentation to confirm that Resident #6's alarms were checked and functioned properly at time of the incident. That same day at 9:55 a.m., the DON told the surveyor that the CNAs were responsible to check the status of the alarms at the beginning of the shift. The DON further stated that information regarding resident care was relayed to the CNA verbally by nursing staff and documented on the CNA's assignment sheet. On 10/18/12 at 10:00 a.m., the facility provided a flow sheet dated 9/13/12 at 1:51 p.m., regarding Resident #6's care however, there was no documented evidence to confirm that the alarms were checked on the 11-7 shift. No further documentation/policy was provided by the facility regarding the incident. The facility policy on Behavior Management dated 4/1/01, and revised on 1/25/12, included "To stimulate differential [DIAGNOSES REDACTED]." In addition, the extensive procedure included but was not limited to; numerous assessment questions to be answered when the resident is exhibiting disruptive behaviors. These include specifics of the behavior, identification of causal factors, assessment of staff response, residents reaction to staff intervention, reassessment of implemented interventions based on response, and facility staff responsible for evaluation/monitoring/oversight, to name a few. There was no documented evidence this policy and procedure was consistently followed. NJAC:8: 39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to provide effective pain management to a resident during treatment of [REDACTED]. This deficient practice resulted in the resident exhibiting evidence of pain by verbally stating that he/she was in pain during the treatment. This deficient practice was identified for 1 of 5 residents reviewed for pain management, Resident #3, as evidenced by the following: The surveyor reviewed the medical record of Resident # 3 on 10/15/12 at 11:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Further review of the medical record revealed a wound consultation dated 6/6/11 which indicated the resident had a Stage IV pressure ulcer on his/her sacrum. The October Physicians Order Sheet (POS) revealed that the resident wore geri-sleeves. The POS also revealed that the resident took [MEDICATION NAME] (a pain medication) every 8 hours around the clock for chronic back pain and generalized body pain and had [MEDICATION NAME] (a pain medication) ordered for "break through pain." On 10/16/12 at 1:15 PM, the surveyor observed a dressing change and treatment of [REDACTED]. The resident was positioned on his/her left side with the help of the Certified Nursing Assistant (CNA). While the resident was on his/her left side waiting for the treatment to begin, he/she called to the nurse and stated "what are you doing I cannot lay like this." As the nurse started the treatment, the resident stated "you are hurting me with your elbow." This statement was directed to the CNA who was holding the resident in position with her upper arms. The CNA repositioned his/her arms, but the resident continued to complain of pain. The resident then requested a pillow to be placed under his/her arm. As the nurse packed the wound, the resident yelled "you are hurting me." The nurse responded "ok we are almost finished." The resident stated "its not ok." The nurse finished the treatment and repositioned the resident on her/his back. Prior to the treatment, the nurse told the surveyor that the resident was last medicated for pain at 6:00 a.m. The treatment began at 1:15 p.m. The nurse did not medicate the resident before the treatment, or stop the treatment when the resident complained of pain. On 10/18/12 at 12:00 p.m. the nurse stated she medicated the resident for pain with [MEDICATION NAME] after the treatment. Review of the facility Pain Management Policy, dated 12/1/01 and revised 5/18/12, revealed the following: " Pain management means the assessment of pain and, if appropriate, treatments in order to assure the needs of the resident of health care facilities who experience problems with pain are met." All residents experiencing acute or chronic pain will have appropriate pain management plan/program formulated....", in additon "...The resident will be provided with the most effective methods of pain relief and their response to the treatment plan will be monitored and adjusted as needed." NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to identify the presence of pressure ulcers on residents until the ulcers had progressed to advanced stages. The facility failed to consistently ensure skin integrity assessments were completed by qualified professional staff. This deficient practice resulted in the discovery of pressure ulcers on residents at Stage II and III, which advanced to Stage IV, and was identified for 2 of 3 residents reviewed for pressure ulcers, Resident #2 and #3, as evidenced by the following: 1. The surveyor reviewed the medical record of Resident #3 on 10/15/12 at 11:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Further review of the medical record revealed a wound consult dated 6/6/11 that indicated the resident had a Stage IV pressure ulcer on his/her sacrum. On 10/16/12 at 11:45 a.m., the surveyor interviewed the Unit Manager (UM) who stated that the pressure ulcer was facility acquired and was found at a Stage III on 3/7/11. The UM provided the surveyor with a care plan (CP) dated from 8/5/10 which identified two Stage III sacral wounds. The CP indicated the following; "Stage III sacral wounds (R) inner buttock 1.5 cm x .25 cm (L) inner buttock 1.5 cm x 2.5 cm Santyl ointment center sacrum 2 cm long." Review of an Interdisciplinary Progress Note (IPN) dated 3/7/11, revealed that a CNA reported three Stage II wounds to the resident's sacrum. The UM further stated that the pressure ulcers migrated together and formed one pressure ulcer which was currently Stage IV. The UM further stated that the resident refused to turn, refused to get out of bed, and was a "heavy wetter." There was no documented evidence in the nurses notes indicating those issues or the facilities response. Further review of the MR at that time revealed an admission Braden Scale (an instrument for predicting pressure sore risk) completed on 7/31/10. The total score was 8, which indicated that Resident #3 was at "severe risk" for acquiring a pressure sore. One of the interventions stated on the CP for skin impairment was to" report redness immediately." The UM, on 10/18/12 at 9:30 a.m., stated that the aides generally inform the nurse of any unusual findings that are observed during care. The UM had no explanation as to why Resident #3's pressure ulcer was found at an advanced stage. Review of policy "Wound and Skin Care , At Risk Residents" on 10/18/12, revealed "All residents identified as high risk will have their skin integrity assessed daily for reddened areas, [MEDICAL CONDITION], and spongy or blistered areas." The policy did not indicate who was responsible to conduct the assessment. 2. On 10/15/12 during the initial tour of the facility, the Unit Manager Nurse (UMN) told the surveyor that Resident #2 had a Stage II facility acquired pressure sore to the right buttock area. On 10/16/12 at 9:05 a.m., the surveyor reviewed Resident #2's clinical record which revealed that the resident had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] and 8/13/12 revealed that Resident #2 required total assistance from staff for bed mobility and transfer, and was incontinent of bowel and bladder. Both MDS assessments indicated that Resident #2 was at risk to develop pressure sores, but the resident's skin was intact at the time of the assessments. Review of the " Braden Scale for predicting Pressure Sores Risk "dated 8/20/12, revealed that Resident #2 was assessed to be at high risk. On 10/16/12 at 10:30 a.m., the UMN told the surveyor that Resident #2 received a foam pressure mattress and a foam cushion for the chair on admission. On 10/16/12 at 10:45 a.m., the surveyor reviewed a Physician order [REDACTED]. " On 10/17/12 at 1:20 p.m., the UMN told the surveyor that the causative factor for the wound was incontinence and impaired mobility. According to the wound tracking form provided by the facility that same day, the wound was identified on 10/12/12 at a Stage 2 and measured 2 cm (centimeter) x 2 cm. On 10/17/12 at 2:00 p.m., the surveyor reviewed a form titled, " Wound Healing Solutions." Under "History of Present Illness" the Wound Consultant documented, " Please note that wound was identified as Stage 2 right gluteus by staff. However, it is better described as left sacrum. " On 10/17/12 at 1:30 p.m., the Certified Nursing Assistant ( CNA ) who cared for the resident on 10/12/12 told the surveyor that during care she observed the open area and reported it to the nurse. An additional interview with the UMN on 10/17/12 at 2:00 p.m confirmed that the CNA reported the open area on 10/12/12. There was no documentation in the clinical record regarding any change in the skin condition. Laboratory values drawn on 10/16/12, 4 days after the wound was identified, revealed a Protein level of 6.3 ( normal values 6.0- 8.3) and [MEDICATION NAME] level of 4.0 normal value ( 3.2-5.0 ). Upon review of the Pressure Sore Policy on 10/17/12 at 2:15 p.m., the surveyor asked for the weekly skin assessment for review, the facility could not provide any evidence regarding weekly skin assessment. On 10/18/12 at 10:00 a.m., the UMN told the surveyor that the CNA's were responsible to assess and document the skin condition daily on the CNA's assignment sheet. A review of the daily assignment sheet dated from 10/1/12 to 10/11/12 revealed that the CNA failed to enter any data regarding Resident #2's skin condition. There was no documentation on the Treatment Administration Record (TAR) regarding Resident #2's skin condition. Review of the facility's Policies and Procedure for wound and skin care, revealed, " Purpose: To prevent pressure ulcer formation in residents identified as high risk for skin breakdown. "Definition High Risk Resident: Those residents who score 16 or less on the Braden Risk Assessment or are assessed by the professional registered to be at risk. Impaired/ decreased mobility and decrease functional ability ... Note: " All residents admitted from an acute care facility will have their skin integrity assessed utilizing the Braden Risk Assessment a minimum of weekly for four weeks. All residents identified as high risk will have their skin integrity assessed daily for reddened areas, [MEDICAL CONDITION], and spongy or blistered areas. " On 10/18/12 at 11:15 a.m., the administrative staff told the survey team that CNA's were responsible for skin assessment. There was no reference made to nursing oversight. However, the facility's policy stated "Skin will be assessed by the nurse." There was no documented evidence the facility policy was consistenly followed. NJAC:8-39-27.1(e)