Every finding on record at Deptford Center for Rehabilitation and Healthcare

COMPLAINT #3064225 Based on observation, interviews, review of medical records and other pertinent facility documentation on 8/3/26 and 8/4/26, it was determined that the facility failed to implement an established care plan intervention for Resident #5 when the resident, who the facility identified as requiring one-on-one supervision for safety reasons, was observed in their room without a staff member. This deficient practice was identified for 1 of 2 residents reviewed (Resident #5) for one-on-one supervision and was evidenced by the following:A review of Resident #5's admission Record revealed that the resident was admitted to the facility with diagnoses that included but were not limited to: psychosis (symptoms that happen when a person is disconnected from reality), schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and a traumatic brain injury. A review of Resident #5's comprehensive Minimum Data Set (MDS), dated [DATE], an assessment tool reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident's cognition was severely impaired. Further review of the MDS indicated that the resident had behaviors which included hallucinations and delusions. A review of Resident #5's care plan revealed a focus related to the resident exhibiting behavior symptoms that included but were not limited to: a history of verbal and physical aggression, auditory hallucinations, and hypersexual behavior. Interventions included but were not limited to one-on-one supervision during each shift, that was initiated on 10/28/25. During a tour of the unit on 8/3/26 at 1:13 PM with the Licensed Practical Nurse/Unit Manager (LPN/UM), the LPN/UM stated that Resident #5 had one-on-one supervision in place which was implemented after a resident-to-resident altercation that involved Resident #5 and that the one-on-one had been in place ever since. She stated that one-on-one supervision means that a resident was to always remain within staff line of sight. As the surveyor and LPN/UM approached the resident's open door, the surveyor observed Resident #5 standing at the bedside and another person was standing next to them. LPN/UM stated that this was a visiting family member. No staff member was observed in the room or in the hallway at that time. When asked if Resident #5 was still within staff's line of sight, the LPN/UM stated that the interdisciplinary team (IDT) decided that the resident was allowed to have private visitation and that the visitor had been educated on informing staff whenever they left the resident's side. Upon completion of the tour, on 8/3/26 at 1:30 PM, surveyor entered Resident #5's room after knocking on the door. The surveyor attempted to engage the resident, who remained nonverbal. During an interview with the visitor, they stated that they had great communication with the staff. The visitor further stated that they were welcome to come and go from the facility as they pleased and that they did not have to tell staff when this occurred. During a joint interview on 8/3/26 at 1:45 PM with the Assistant Director of Nursing (ADON) and the Licensed Nursing Home Administrator (LNHA), the ADON stated that she was familiar with Resident #5 and that the resident required one-on-one supervision. When asked if that supervision could be performed by visitors, as the UM stated that for privacy reasons the visitor could complete the task, the ADON stated that she would have to verify. During a follow-up interview on 8/3/26 at 2:54 PM the ADON stated that all residents that required one-on-one supervision must always be within staff line of sight. During a joint interview on 8/4/26 at 3:20 PM with the Director of Nursing (DON) and the LNHA, the DON stated that there was no policy in place for one-on-one supervision. She stated that the one-on-one was established due to an isolated incident. She stated that staff education on one-on-one occurred monthly and included that the residents were to always remain within line of sight of staff. She stated that Resident #5 should have been in staff line of sight. The surveyor attempted to contact the Certified Nursing Assistant (CNA) that was assigned to Resident #5 on the 8/3/26, day shift, for an interview but was not successful. A review of the facility's CARE PLANS- COMPREHENSIVE policy, revised 10/2025, revealed that the established person-centered care plans included services that were to be implemented for each resident to maintain their highest level of well-being. A review of the facility's ABUSE policy, revised 7/18/25, revealed under the Protection section that residents would be ensured safety and that one-on-one monitoring would be provided, as appropriate. A review of the facility's SUPERVISION-ENHANCED MONITORING policy, created 5/27/26, revealed that residents would be ensured a safe and secure environment through the development of resident-centered actions, including appropriate supervision. N.J.A.C. 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to ensure that a resident's physician ordered medication was signed as administrated at the time of administration in accordance with professional standard of practice. This deficient practice was identified for 1 of 9 residents reviewed for standards of practice (Resident #7).The evidenced was as followed: Reference: 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 otherwise legally authorized Physician or Dentist. A review of the admission Record (AR) revealed that Resident #7 was admitted to the facility with diagnoses that included but were not limited to; acute right heart failure, diabetes, major depressive disorder, and muscle weakness. A review of Resident #7's quarterly Minimum Data Set (MDS), an assessment tool dated 8/27/25, revealed that the resident had a Brief Interview Mental Status (BIMS) score of 15 out of 15, indicating that the resident's cognition was intact. A review of Resident #7's September 2025 Medication Administration Record (MAR), located in the electronic medical record, included a physician's order (PO) dated 3/17/25, for levothyroxine sodium oral tablet 88 micrograms (mcg); give one tablet by mouth in the morning for hypothyroid. The MAR was blank on 9/19/25, for the administration. On 10/8/25 at 1:00 PM the surveyor requested from the Director of Nursing (DON) a copy of Resident #7's September 2025 MAR. A review of Resident #7's September 2025 MAR provided by the DON revealed that the levothyroxine was signed as administered for the 9/19/25 at 6:00 AM dose. On 10/9/25 at 1:15 PM, the surveyor requested from the DON a copy of Resident #7's Medication Admin Audit Report for September 2025. On 10/9/25 at 1:22 PM, the DON provided Resident #7's September 2025 Medication Admin Audit Report. At that time, the surveyor reviewed the report, which revealed Resident #7's scheduled 9/19/25 at 6:00AM, levothyroxine dose was signed as administered on 10/9/25 at 1:06 PM. On 9/8/25 at 1:31 PM, the DON reviewed Resident #7's Medication Admin Audit Report and confirmed the 9/19/25, dose of the levothyroxine was signed as administered on 10/9/25 at 1:06 PM. The DON stated that medication administration should be documented immediately after the medication was administered. The DON further stated that her expectation was that the nurse signed for the administration of the medication at the time of administration. On 10/8/25 at 1:46 PM, the surveyor interviewed the License Practical Nurse (LPN), who was assigned to administer Resident #7's levothyroxine on 9/19/25 at 6:00 AM. The LPN stated that she administered the medication, but she forgot to sign the MAR. A review of the facility's policy Medication Administration with a revision date of 12/2019, revealed under Procedure number 12., The individual administrating the medication must initial the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones. NJAC8:39-11.2(b)

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: On 8/8/25 at 9:58 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The microwave had multicolored dried stuck on debris on the interior ceiling of the unit. The FSD acknowledge it was not properly cleaned according to facility policy. 2. The convection ovens were soiled with baked on brown coloring on the glass doors making them opaque and not transparent. There were baked on debris on the interior corners of the units. The FSD acknowledged and stated, it was not cleaned according to facility policy. 3. The six-burner stove top and oven were not clean. The interior of the oven had food sediment and build up on the interior door. The catch tray that was lined with foil had burnt liquid, and food debris covering the entire tray and foil that was peeling. The FSD acknowledged and stated, it was not cleaned according to facility policy. 4. The griddle top and the splash guard surround had crusted, hardened, and scrapeable black debris. The FSD acknowledged and stated, it was not cleaned according to facility policy. 5. The fryer had food debris on the ledge of the oil well and the oil was dark brown in color during the ladle check. The FSD acknowledged and stated, that it was not cleaned according to facility policy. 6. The can opener blade had a metal chip on right side and food debris that were brown in color and sticky located on shaft near blade and holder. The FSD stated, the blade had not been changed since she started at the facility and there was not a maintenance log in place on when to replace the blade or a cleaning log for the can opener. The FSD acknowledged that it was not cleaned according to facility policy. On 8/8/25 at 10:45 AM, the surveyor interviewed the FSD, who acknowledged the surveyors finding and stated the equipment should have been cleaned and maintained in a sanitized way to prevent food borne illness and contamination for safety of the residents and staff. On 8/14/25 at 11:43 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who acknowledged the surveyors concerns after reviewing the pictures of the kitchen equipment. The LNHA stated the equipment should be cleaned and maintained to prevent food borne illness, contamination, or injury. He further stated it should be cleaned to ensure the safety of the residents and staff. On 8/18/25 at 9:47 AM, the survey team met with the LNHA, Assistant LNHA, Regional Clinical Director (RCD), and the Director of Nursing (DON), who all acknowledged the surveyor's concerns. No additional information was provided. A review of the facility's, Food and Nutrition Services, dated, January 2023, included policy statement.The food service area shall be maintained in a clean and sanitary manner.All kitchen areas, food service areas, and dining areas shall be kept clean, free from debris and protected from rodents, roaches, flies and other insects. The FSD will be responsible for scheduling staff for regular cleaning of the kitchen. NJAC 8:39-17.2(g)

Based on interview and document review, it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA) a.) received a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI) and b.) funds and final accounting of those funds were conveyed within 30 days of the resident's discharge or death to the proper jurisdiction.This deficient practice was identified for 12 of 13 residents (Resident #6, #39, #80, #159, #173, #186, #239, #241, #243, #245, #248 and #249) reviewed for PNA and was evidenced by: 1.) On [DATE] at 12:00 PM, the Licensed Nursing Home Administrator (LNHA) provided the PNA balances as of [DATE]. A review of the facility's Trial Balance revealed 12 residents had balances that ranged from $1,964.18 to $39,870.91.On [DATE] at 10:48 AM, the surveyor interviewed the Regional Director of Finance (RDF) who stated that she was covering for the Finance Coordinator (FC) who was currently on vacation. The RDF stated that the quarterly PNA balance statements were sent out and that they informed the resident or the resident's representative that the balance was high. On [DATE] at 10:12 AM, the RDF and the surveyor reviewed the Resident Activity List, and the RDF confirmed it was for [DATE], which was the last quarterly and during the month of [DATE] the PNA statements were distributed.At that time, the surveyor and RDF then reviewed the Resident Statement Landscape which indicated the following:Resident #6 had an account balance of $7,014.28 as of [DATE]. The RDF stated that the resident had an overpayment that was returned [DATE] after surveyor inquiry. Resident #39 had an account balance of $2,254.28 as of [DATE]. The RDF stated that the resident's quarterly statement was mailed and emailed to the Office of Public Guardianship (OPG). Resident #80 had an account balance of $2,051.48 as of [DATE]. The RDF stated that the quarterly statements were left at the front desk for when the resident's representative stated they were coming to visit that month. Resident #159 had an account balance of $2,081.13 as of [DATE]. The RDF stated that the quarterly statements were mailed to the resident's representative. Resident #173 had an account balance of $3,092.55 as of [DATE]. The RDF stated that the resident had an overpayment that was returned [DATE] after surveyor inquiry. Resident #186 had an account balance of $2,196.42 as of [DATE]. The RDF stated that the quarterly statements were mailed to the resident's representative. On [DATE] at 10:23 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the facility sent out the quarterly statement but not a written notification letter. He stated he just found out that there was a letter that could be sent out. On [DATE] at 11:51 AM, during a follow-up interview the RDF stated she was not aware of any letter that was sent out to the resident to inform them they were approaching the limit that could jeopardize a resident's eligibility for Medicaid or SSI until recently. When asked how the resident or the representative would know, she stated they received their quarterly statements and that they were aware of the risk during enrollment that they were not to go over $2,000.00. The RDF then stated that they did encourage residents to spend down their monies. 2.) On [DATE] at 9:55 AM, the surveyor interviewed the RDF who stated that after a resident was discharged or deceased , within 30 to 60 days the monies should be returned to the appropriate party. She stated that sometimes it could take longer depending on the situation but generally the process to return the funds should be started right away. On [DATE] at 11:02 AM, the surveyor reviewed the electronic medical records (EMR) census which reflected the following: Resident #239 expired on [DATE]. Resident #241 expired on [DATE].Resident #243 was discharged on [DATE].Resident #245 was discharged on [DATE]. Resident #248 was discharged [DATE]. Resident #249 expired on [DATE]. On [DATE] at 10:12 AM, the RDF and the surveyor reviewed the Resident Activity List, and the RDF confirmed it was for [DATE], which was the last quarterly. At that time, the surveyor and RDF then reviewed the Resident Activity List and the Resident Statement Landscape as of [DATE] which indicated the following:Resident #239 had an account balance of $2,227.96 with interest being paid, was deceased , and the funds were not returned to Medicaid within 30 days. Resident #241 had an account balance of $1,964.18 with interest being paid, was deceased , and the funds were not returned to Medicaid within 30 days. Resident #243 had an account balance of $39,870.90 with interest being paid, was discharged but then expired, and the funds were not returned within 30 days. The RDF stated she was waiting on the PR-1 form (used to determine how much of a Medicaid recipient's income is available to offset the cost of their long-term care in a nursing facility) and confirmation on what to do with the funds from [name redacted] county. Resident #245 had an account balance of $2,465.87, was discharged to the hospital, later transferred to another facility, and the funds were not transferred. A review of the Resident Activity List indicated the resident's representative who worked at the facility received the quarterly statements. Resident #248 had an account balance of $16,327.70 with interest being paid, was discharged , and the funds were not returned to the State.Resident #249 had an account balance of $4,882.23 with interest being paid, was deceased , and the funds were not returned to Medicaid. At that time, the RDF stated she would have to follow up with the FD on why the funds were just now being returned. She acknowledged the funds should have been returned prior to surveyor inquiry. On [DATE] at 10:20 AM, in the presence of the Assistant LNHA (ALNHA) and the Corporate Support (CS) the surveyor interviewed the LNHA who stated they tried to contact the resident or representative within 30 days of the funds, but not all residents had families or guardianship. On [DATE] at 9:49 AM, the LNHA and ALNHA acknowledged in the presence of the Director of Nursing (DON), the Regional Clinical Director (RCD) and the survey team that the written notification letter should have been sent out to the resident reaching the maximum amount and the monies should have been sent back within 30 days of the resident being discharged or deceased . A review of the facility's Resident Funds Account (RFA) policy date revised [DATE], included, 11. The facility will notify residents who receive Medicaid benefits when their Resident Funds Account reaches $200.00 less than the Medicaid/SSI resource limit and will explain to the resident the criteria under which the resident may lost eligibility for Medicaid/SSI. 12. Upon discharge of a resident: a. the facility shall refund any balance of resident funds held by the facility to the resident or authorized representative.not to exceed thirty (30) days from the date of discharge 13. Upon resident death funds shall be conveyed.within 30 days. NJAC 8:39-9.5

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure an accurate account of the administration and documentation of controlled medications.This deficient practice was identified for 1 of 3 nurses on 1 of 8 nursing units (2 D) reviewed during the medication administration and storage observation and was evidenced by the following: On 8/12/25 at 8:57 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 administer six (6) medications to Resident #128 during the medication administration observation. When finished, the surveyor requested to review the Shift Count narcotic inventory log. The surveyor reviewed the Shift Count for the 8/12/25 for the 7 AM - 3 PM shift and noted that the designated area for Is Count Correct and EDK [Emergency Drug Kit] Sealed were not answered with a Yes or No response and both areas were blank. There were two illegible signatures in the area designated for the nurse's signature that was coming on duty and the nurse's signature for going off duty. The surveyor asked LPN #1 if she signed the Shift Count to confirm accuracy of the controlled medications in the cart prior to receipt at shift change? LPN #1 stated that she did not sign the Shift Count because the 11 PM -7 AM nurse had the book signing out her medications, so she did not sign the Shift Count. LPN #1 further stated that the narcotic count was done and there were no discrepancies. At that time, the surveyor requested to view and count the full controlled medication inventory with LPN #1. LPN #1 then proceeded to remove the bingo card (medication dosing system with multiple doses of a medication that are sealed separately in a bubble pack on a card with foil backing) of Clonazepam 0.25 milligrams (mg) (used to treat panic disorder/seizures) tablets and the Declining Inventory Sheet (DIS) indicated that there were 21 tablets remaining. Upon inspection of the bingo cards, there were only 20 tablets of Clonazepam 0.25 mg remained. When interviewed, LPN #1 stated that she administered the medication to Resident #99 at 8:00 AM, but she had not signed out the dosage on the DIS because the 11-7 nurse retained the book to sign out the controlled medications that she had administered during the 11-7 shift. LPN #1 stated that it was important to sign the DIS at the time the controlled medication was removed from the bingo card so that you did not miscount and there was proof of medication administration. LPN #1 then proceeded to count the inventory of Lyrica 75 mg tablets (used to treat nerve pain/seizures) and the DIS indicated that there were 55 tablets remaining, and upon inspection, only 54 tablets remained. LPN #1 stated that she administered the medication to Resident #152 but was unable to sign the book because the 11-7 nurse still had the book. LPN #1 then proceeded to count the inventory of Alprazolam 1 mg tablets (used to treat anxiety/panic disorder) and the DIS indicated that there were 58 tablets remaining, and upon inspection, only 57 tablets remained. LPN #1 stated that she could not sign the book because the 11-7 nurse still had the book. On 8/12/25 at 9:21 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that it was very important for both the oncoming and outgoing nurses to count the controlled medications together and sign the book upon completion to ensure that the narcotic count inventory was correct and there were no medication errors. LPN/UM #1 stated that as soon as the controlled medication was popped from the bingo card for administration the medication should be signed out on the DIS to ensure that there were no medication errors and that everything was accounted for. LPN/UM #1 stated that once the medication cart controlled medication inventory was counted, and the keys were handed off the nurse assuming the cart should have the book, keys and cart in their possession. LPN/UM #1 further stated that the book should not be retained by the nurse going off duty because you do not know what may be written in the book after you have counted the inventory. On 8/12/25 at 9:21 AM, the surveyor interviewed the Director of Nursing (DON) who stated that it was important to do the shift-to-shift count to ensure that the narcotic count was accurate. The DON stated that the incoming nurse should have notified the DON to obtain the book from the 11-7 nurse at shift change. The DON stated that the incoming nurse should assume responsibility of the narcotic book because they were responsible for the narcotic inventory in the cart during their shift. The DON stated that she counted with the 11-7 nurse at 6:50 AM, and the cart was accurate, because LPN #1 was late. The DON further stated that it was LPN #1's fault for not signing out the medications at the time of administration because all of the nurses have been in-serviced for once you have given a narcotic, you are to sign it out immediately. The DON further stated that the nurse was required to sign the book the moment that the drug was popped out of the bingo card to ensure that the controlled medication was accounted for. On 8/18/25 at 9:36 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) was made aware of the concerns related to the lack of accountability with the controlled medication storage inventory and documentation. A review of the facility's Controlled Substance Management policy, created August 2022, included: .Separate records shall be maintained on all controlled substances in the form of a declining inventory record. Such records shall be accurately maintained and shall include a. the name of the resident. b. The name of the prescriber. c. The prescription numbers. d. The drug names. e. The form of the medication. f. The strength of the medication. g. The strength of the dose administered. H. The date and time of administration. i. The signature of the person administering the drug. Such records shall be reconciled by the incoming and outgoing nurse. Two nurses must count the remaining medication at each shift, and any handoff of narcotic keys All controlled substances shall be counted at the change of each shift by the incoming and outgoing nurse.Any discrepancy in the count of controlled substances is to be reported immediately to the Nursing Supervisor and a signed entry shall be recorded on the page where the discrepancy is found .The medication nurse is responsible for adhering to the procedures for ordering receiving, storing, administering and recording the administration of controlled drugs .NJAC 8:39-29.7(c), 29.2(d)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to respond to comments/recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 1 of 5 residents (Resident #185) reviewed for Unnecessary Medications and was evidenced by the following:A review of Resident #185's Order Summary Report (OSR) revealed a Physician's Order (PO) dated 4/9/25, for Fludrocortisone Acetate (used to treat certain conditions in which the adrenal glands (a gland) cannot make enough hormones such as Addison's Disease) Oral Tablet 0.1 milligrams (mg) (Fludrocortisone Acetate) Give one (1) tablet by mouth one time a day for Syndromes. The surveyor reviewed the diagnoses listed on the resident's OSR which failed to include a medical diagnosis of syndromes. A review of Resident #185's August 2025 Medication Administration Record (MAR) revealed that the resident was ordered Fludrocortisone Acetate Oral Tablet 0.1 MG (Fludrocortisone Acetate) Give 1 tablet by mouth one time a day for Syndromes. The medication was scheduled to be administered between 7 AM - 10 AM and had been administered daily from 8/1/25 through 8/15/25. A review of the Consultant Pharmacist Inspection Report dated 5/2/25, revealed a recommendation to, Please clarify fludrocortisone ordered for syndromes. The Physician/Prescriber response: indicated a checked box which specified Agree with the recommendation and a signature was noted in the space provided for a Physician Signature.A review of a Consultant Pharmacist Consultation Note dated 6/6/25 at 12:30 PM revealed: Medication Regimen Reviewed. No recommendations made.A review of a Consultant Pharmacist Consultation Note dated 7/7/25 at 3:12 PM, revealed: Medication Regimen Reviewed. No recommendations made. On 8/14/25 at 11:44 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that the Consultant Pharmacist Recommendations were forwarded to her from the Director of Nursing (DON) via email. LPN/UM #2 stated that she then printed the recommendations out and gave them to the Nurse Practitioner (NP) for review. LPN/UM #2 stated that the NP would then sign the recommendation if she was in agreement and then we would carry out the recommendations and make the changes to the resident's medication orders at that time. The surveyor then presented LPN/UM #2 with the Consultant Pharmacist Inspection Report dated 5/2/25, in which the NP signed that he/she was in agreement with the CP recommendations to clarify fludrocortisone ordered for syndromes, and the recommendation was not addressed. LPN/UM #2 stated that the order should have been changed and returned to her by the next monthly review, as she did not believe that syndromes was an appropriate diagnosis for the medication. On 8/14/25 at 2:08 PM, the surveyor interviewed the facility supplier pharmacy Morning Supervisor who stated that fludrocortisone was originally ordered on 8/18/22 for an indication of syncope (temporary loss of consciousness caused by a fall in blood pressure). He further stated that when the medication was reordered on 4/9/25, the indication for syndromes was not clarified. On 8/14/25 at 2:30 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that the facility changed Consultant Pharmacist Providers back in June of 2025. The ADON stated that the CP emailed the recommendation to her or the Director of Nursing (DON), and the recommendations were printed out and were then given to the physician for review to see if they agree or disagree. The ADON stated that if the physician did agree, then they updated the order, and we make sure that the recommendation was followed through. The ADON stated that the NP should have provided the correct diagnosis if she signed off in agreement. The ADON stated that the Unit Manager sat down and went over the recommendations with the NP and the recommendation should have been clarified at that time. On 8/18/25 at 9:36 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) was made aware of the concerns related to the failure of the facility to act upon the Consultant Pharmacist recommendations in a timely manner. A review of the facility's Medication Regimen Reviews (MRR) policy, revised November 2021), included: The Consultant Pharmacist reviews the medication regimen of each resident at least monthly The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences.The attending physician documents in the medical record the irregularity has been reviewed and what (if any) action was taken to address it within 30 days of receiving the report. NJAC 8:39-29.3(a)1, b

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a low-air-loss mattress was operating and set according to the resident's weight, as per a physician's order for a resident previously identified as being at risk for impaired skin integrity.This deficient practice was identified for 1 of 4 residents (Resident #7) reviewed for positioning and mobility, and was evidenced by the following:On 8/8/2025 at 10:46 AM, the surveyor observed Resident #7 lying in bed awake. The mattress was noted to be inflated; however, the air loss mattress (a mattress used to prevent and treat pressure ulcers) was not on at that time. There was a piece of tape on the machine, with weight 235 pounds (lbs), written on it.On 8/13/2025 at 11:08 AM, the surveyor conducted a follow-up visit to the resident's room. Resident #7 was observed lying in bed and the air mattress was set to 250 lbs.A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: obesity, edema, and muscle weakness.A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool, dated 7/17/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact.A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 1/18/2022, included that the resident was at risk for impaired skin integrity related to fragile skin. The interventions included: Low air loss mattress to bed and check air mattress for functioning every shift.A review of the Order Summary Report (OSR), included the following physician orders (PO):A PO, dated 4/10/2025, for Low air loss mattress and to check the setting closest to resident's current weight, and check the mattress functionality.A review of the August 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that the low air mattress was signed off by the nurse as administered on 8/8/2025 and 8/13/2025.A review of the weights in the resident's electronic health record (EHR) indicated that on 8/12/2025, the resident weighed 193 lbs.On 8/13/2025 at 12:05 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #2, who stated that the settings on the low air loss mattress should be checked daily to ensure that it was on the correct setting. She further noted that if it was not set correctly, it can cause an injury to the resident or worsen a pre-existing injury.On 8/13/2025 at 12:15 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #3, who stated that the low air loss mattress should be functioning and set according to the resident's weight. She further noted that the setting should not go beyond the resident's weight, and on every shift, the Certified Nurse Aides (CNAs) and LPNs should ensure that it was working and functioning.At that time, the surveyor was accompanied by LPN/UM #3 to the resident's room. The LPN/UM confirmed that the setting was on 250 lbs and should have been set to 200 lbs.On 8/13/2025 at 1:07 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the PO specified the air loss mattress should be set to the number closest to the resident's weight. She further noted that the nurses should follow the care plan and the physician's orders, and ensure that it was turned on and at the correct settingA review of the facility's Support Surfaces- Air Mattress dated February 2019 included, It is the policy of the facility to provide an environment of care that promotes the highest quality of care and comfort for residents. This includes the treatment and prevention of pressures with the use of support surfaces. NJAC 8:39-27.1(a)

Based on interview, record review, document review, and policy review, the facility failed to provide quality care in accordance with physician orders for one Resident (R) 9) of three residents reviewed for outside appointments out of a total sample of 22 residents. Specifically, the facility failed to ensure R9 had a gastric emptying scan as ordered. This had the potential for R9 and other residents to have medical issues related to missed procedures. Findings include: Review of the facility's policy titled, Physician Consultations revised on 08/2019, provided by the Director of Nurses (DON) documented It is the policy of this organization to ensure all residents receive medical care in a timely manner . The attending physician will approve orders based on the consultant recommendations .The attending physician will be responsible for following up on the effects of recommended medications and treatments . Review of the Admission Record under the Profile tab of the electronic medical record (EMR) documented R9 was admitted to the facility on [DATE] with diagnoses Gastroesophageal Reflux Disease (GERD) and anxiety disorder. Review of the Care Plan under the Care Plan tab of the EMR dated 10/07/24, documented R9 had GERD related to hyper acidity and interventions included obtain and monitor lab/diagnostic work as ordered and refer to Gastroenterologist as needed. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/24 located under the MDS tab of the EMR revealed R9's Brief Mental Status Interview (BIMS) score was 15 out of 15 indicating intact cognition. Review of R9's Progress Note under the Progress Note tab of the EMR dated 07/31/24 documented, Resident scheduled for gastric emptying scan (gastric emptying study measures how long it takes food to pass from your stomach into your small intestine. The test helps doctors diagnose issues related to slow or rapid stomach emptying. Evaluate symptoms like nausea, vomiting, abdominal pain, or bloating) on August 1st at 8AM .resident and resident's mother notified of upcoming appointment date/time/location. Review of R9's Progress Note dated 08/01/24 documented, Resident left for appointment via transport. Review of R9's Progress Note dated 08/01/24 documented, Resident returned via transport. During an interview on 02/24/25 at 9:56 AM, R9 stated that he/she has nausea and vomiting, believed he/she had abdominal paralysis (a condition where the stomach muscles do not function properly, leading to delayed or incomplete emptying of food into the small intestine), and last year the Physician ordered a gastric emptying test. He/she stated although he/she went to the appointment, he/she vomited prior to the test, which was not able to be completed, was transferred back to the facility, and the test was to be rescheduled. R9 stated although he/she has told several staff he/she still needed the procedure, the test had not been rescheduled. On 02/26/25 at 8:30 AM, Licensed Practical Nurse (LPN) 6 stated R9 had a gastroenterology appointment on 07/03/24 with a recommendation for a gastric emptying scan on 08/01/24, which was not completed due to R9 vomiting prior to the procedure. She stated when R9 returned to the facility, the scan needed to be rescheduled. LPN6 said she could not recall if she alerted the Medical Records staff to reschedule the test and notified the medical staff. LPN6 stated there was no documentation in the EMR or hard copy chart that the medical staff had been alerted, and the appointment was rescheduled. Review of R9's appointment log provided by the Medical Records person documented an appointment with the Gastroenterologist on 07/03/024 which was completed and an appointment at the hospital for a test on 08/01/24, which was completed. During an interview on 02/25/25 at 9:26 AM, the Medical Records person stated she receives information related to outside appointments for residents from the nurses. She stated when R9 refuses a test or consultation, the nurse notifies her, and she reschedules the appointment. She stated she scheduled R9's gastric emptying scan for 08/01/24. The Medical Records person stated she was not notified the gastric emptying test was not completed, assumed it was completed, and therefore, did not reschedule the appointment. During an interview on 02/26/25 at 11:32 AM, the Director of Nursing(DON) stated R9 had not had his/her gastric emptying scan completed. She stated there was a break in communication between the medical records person and nursing in rescheduling the scan. The DON stated her expectation was that consultations, scans, etc. were completed timely, and the Physician or Nurse Practitioner (NP) was to be notified if there were issues with the completion of consultations and/or procedures. During an interview on 02/25/25 at 10:10 AM, NP1 stated she was not aware R9 had not had the gastric emptying scan and that the scan had not been rescheduled NP1 stated her expectation was that if R9 did not go to a scheduled appointment and the appointment was not rescheduled, she was to be notified. NJAC 8:39-27.1(a)

C# NJ166810 C# NJ167847 C# NJ168096 Based on interview, document review, and review of facility policy, the facility failed to ensure four residents (Resident (R) 6, R9, R25, and R30) of 31 sampled residents reviewed for abuse were free from resident-to-resident abuse perpetrated by R5. This had the potential to affect resident safety at the facility. Findings include: Review of R5's electronic medical record (EMR) titled Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia and Alzheimer's disease. Review of R5's EMR titled Care Plan located under the Care Plan tab, dated 05/07/24, indicated the resident had a history of behaviors such as making false accusations of assault or missing money, yelling at staff and residents, cursing, and aggression toward other residents. Review of R5's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/24 and located under the MDS tab, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period. 1. Review of R6's electronic medical record (EMR) titled Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including lung cancer and dementia. Review of R6's EMR titled Care Plan located under the Care Plan tab, dated 06/08/23, indicated the resident had a history of behaviors such as using racial slurs, wandering, and cursing at residents. The care plan indicated R6 had severe memory impairment due to her diagnosis of dementia. The care plan indicated the resident was at high risk for experiencing abuse. Review of R6's EMR annual MDS with an ARD of 05/12/24 and located under the MDS tab, indicated the resident had a BIMS score of six out of 15 which indicated the resident was severely cognitively impaired. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period. Review of R5's Progress Notes, dated 08/14/23 and located in the EMR under the Progress Notes tab, revealed the resident was involved in a witnessed event during which the resident argued with R6 in the hallway, was separated from R6, and then ran back down the hallway toward R6 and hit R6 on her left shoulder three times. Review of a document provided by the facility titled Investigation Report, dated 08/16/23, indicated R5 and R6 were immediately separated, and an investigation was initiated related to the alleged abuse. The record indicated no injury to either resident related to the incident. The investigation findings indicated abuse could not be substantiated due to the event was not predictable and was an isolated event. The documentation read, in pertinent part, Any reasonable person would conclude the event was unavoidable due to residents psychiatric diagnosis in conjunction with presenting behaviors. 2. Review of R9's EMR titled Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia and depression. Review of R9's EMR titled Care Plan located under the Care Plan tab, dated 10/04/23, indicated the resident had a history of experiencing hallucinations and delusions. The care plan indicated R9 was at high risk for experiencing abuse. Review of R9's quarterly MDS with an ARD of 05/11/24 and located in the EMR under the MDS tab, indicated the resident had a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. The assessment indicated the resident experienced delusions during the assessment reference period. Review of R5's Progress Notes located in the EMR under the Progress Notes tab, indicated a second event, dated 09/09/23 during which R9 reported R5 entered her room and punched her on her left leg. The record indicated R5 stated she punched R9 on the leg because she thought someone had taken her money. Review of a document provided by the facility titled Investigation Report, dated 09/10/23, indicated R5 and R9 were immediately separated, and an investigation was initiated related to the alleged abuse. The record indicated no injury to either resident related to the incident. The investigation findings indicated abuse could not be substantiated due to the event was not predictable and was an isolated event. The documentation read, in pertinent part, Any reasonable person would conclude the event was unavoidable due to residents psychiatric diagnosis with presenting behaviors in conjunction with diagnosis of chronic UTIs (urinary tract infections). This was an isolated event. 3. Review of R25's EMR titled Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors. Review of R25's EMR titled Care Plan located under the Care Plan tab, dated 11/03/20, indicated the resident was severely cognitively impaired and had a history of exhibiting behaviors such as verbal and physical aggression toward other residents. The care plan indicated R25 was at high risk for experiencing abuse. Review of R25's quarterly MDS with an ARD of 04/01/24 and located in the EMR under the MDS tab, indicated the resident had a BIMS score of 99 (the assessment was not able to be completed due to the resident's poor cognition). The assessment indicated the resident did not exhibit any behaviors during the assessment reference period. Review of R5's Progress Notes located in the EMR under the Progress Notes tab, indicated a third event, dated 08/19/23 during which R5 was witnessed by staff charging at R25 and repeatedly stabbing him/her with an ink pen, causing two small skin tears on R25's right forearm. Review of a document provided by the facility titled Investigation Report, dated 08/21/23, indicated R5 and R25 were immediately separated, and an investigation was initiated related to the alleged abuse. R25 was treated for his/her skin wounds. The investigation findings indicated abuse could not be substantiated due to the event was not predictable and was an isolated event. The documentation read, in pertinent part, Any reasonable person would conclude the event was unavoidable due to residents psychiatric diagnosis in conjunction with diagnosis of UTI. 4. Review of R30's EMR titled Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors. Review of R30's EMR titled Care Plan located under the Care Plan tab, dated 01/06/21, indicated the resident was severely cognitively impaired and had a history of exhibiting behaviors such as yelling out, banging on doors, and raising her fist and yelling at staff. The care plan indicated R30 was at high risk for experiencing abuse. Review of R30's quarterly MDS with an ARD of 04/29/24 and located in the EMR under the MDS tab, indicated the resident had a BIMS score of three out of 15, which revealed the resident was severely cognitively impaired. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period. Review of R5's Progress Notes located in the EMR under the Progress Notes tab, indicated a fourth event, dated 09/01/23 during which R5 was witnessed by staff standing over R30, screaming, and cussing and grabbing his/her arm. The documentation indicated R30 was yelling out [R5]'s hurting me! The documentation indicated R30 sustained a superficial scratch to his/her right arm related to the incident. Review of a document provided by the facility titled Investigation Report, dated 09/02/23, indicated R5 and R30 were immediately separated, and an investigation was initiated related to the alleged abuse. R30 was treated for her skin wound. The investigation findings indicated abuse could not be substantiated due to the event was not predictable and was an isolated event. The documentation read, in pertinent part, Any reasonable person would conclude the event was unavoidable due to residents psychiatric diagnosis with presenting behaviors in conjunction with diagnosis of chronic UTIs. Review of the facility's Accident/Incident Log and Reportable Events Log, both dated 05/01/23 through 05/20/24, revealed four separate incidents between R5 and different residents during which R5 exhibited abusive behavior to these residents. All the incidents occurred between 08/14/23 and 09/09/23. No further incidents were documented in either of the logs after 09/09/23 related to R5 and resident to resident abuse. Continued review of R5's record indicated no additional incidents of potential resident to resident abuse involving the resident. The record indicated the last incident of potential resident to resident abuse related to R5 occurred on 09/09/23. The record indicated interventions, such as increased supervision of R5 and moving R5 into a private room immediately across from the nurse's station, had been implemented since 09/09/23 to prevent further incidents. During an interview on 05/22/24 at 10:30 AM, Unit Manager (UM) 1 indicated she was very familiar with R5 and confirmed R5 had been the instigator in multiple resident-to-resident incidents of abuse during the summer/fall of 2023. She confirmed interventions had been put into place since that time and stated she was not aware of any recent incidents of alleged abuse involving R5. She stated, We have eyes on [R5] at all times. [R5] did have quite a few resident to resident (altercations). [R5] is better now. [R5] seems a little more calm in a private room and we keep [R5] away from other residents, which is his/her preference anyway. We have not had any resident to resident for a while now with [R5]. UM 1 stated R5 getting physical with other residents should be considered abuse. During an interview on 05/22/24 at 10:40 AM, Certified Nursing Assistant (CNA) 13 confirmed she was familiar with R5 and confirmed R5 had a history of resident-to-resident incidents of abuse in the past. CNA13 stated she had not seen any physical altercations between R5 and other residents in a while. CNA13 stated, [R5] is close (to the nurse's station) and in our line of site now, so we can intervene with him/her before anything even happens. I know [R5] and how to intervene. During an interview on 05/22/24 at 10:45 AM, CNA14 confirmed she was familiar with R5 and stated R5 had been involved in multiple resident-to-resident physical altercations in the past but stated she had not witnessed any recent events involving R5 and other residents. During an interview on 05/22/24 at 10:50 AM, Licensed Practical Nurse (LPN) 8 confirmed she was familiar with R5 and stated the resident had been involved in quite a few resident to resident physical altercations in the past, but she had not witnessed anything recently. She stated, We do what we need to calm [R5] down. I cannot pinpoint any physical altercations recently. But [R5] has had in the past. At one point in time there were quite a few .[R5] has a private room now because we couldn't take a chance with roommates, [R5] stays in his/her favorite spot, and [R5] writes notes with his/her pen and a book. During an interview on 05/22/24 at 11:55 AM, the Director of Nursing (DON) stated the facility's Administrator was the Abuse Coordinator, however she was responsible for ensuring investigations into allegations were completed and completing the investigation findings report based on the investigation results. The DON stated R5 had frequent urinary tract infections, and because of her diagnosis of recurrent UTI's, abuse had not been substantiated for any of the above referenced incidents of resident-to-resident physical abuse. The DON further stated her understanding was if staff had not done anything to purposefully instigate resident to resident abuse between residents, abuse could not be substantiated. She stated, I did not understand that resident to resident abuse was a thing. I was referencing staff in all (of the investigations) and saying that the staff did not coerce any resident to be abusive (and so no abuse occurred). During an interview on 05/22/24 at 12:30 PM, the Administrator stated his expectation was any resident altercation during which there was an intent to do harm to another person should be considered abuse. Review of the facility's policy titled, Abuse, dated 12/22 and provided by the facility, indicated The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility; and Physical Abuse: includes hitting, slapping, pinching, scratching, spitting, holding roughly, kicking, etc. It also includes controlling behavior through corporal punishment. NJAC 8:39-4.1(a)5

12679 C# NJ165261 C#NJ165932 C#NJ166156 C#NJ166810 C#NJ167718 C#167847 C#NJ168096 C#NJ168350 C#NJ168593 C#NJ171428 Based on interview, document review, and review of facility policy, the facility failed to ensure the facility reported the results of their abuse/neglect investigations to the State Survey Agency (SSA) within five working days for 10 out of 13 residents (Resident (R) 3, R4, R5, R6, R9, R2, R11, R7, R31, R14) reviewed for abuse of 31 sampled residents. This failure had the potential to delay corrective measures and appropriate response to abuse allegations ensuring the safety of the residents. Findings include: 1. Review of R3's electronic medical record (EMR) titled Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of vascular dementia. Review of R3's EMR titled Care Plan located under the Care Plan tab, dated 02/19/18, indicated the resident had a history of behaviors such as screaming and cursing at staff. The Care Plan revealed the resident had a history of confabulation (false memory creation). Review of R3's EMR significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/11/23 and located under the MDS tab, indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated the resident made verbal threats, such as screaming and threatening others. Review of R3's EMR titled Registered Nurse [RN] Assessment, dated 07/10/23 and located under the Progress Notes tab, indicated the resident informed staff that a Licensed Practical Nurse (LPN) 4 choked her. Review of a document provided by the facility titled Investigation Report, dated 07/12/23, indicated LPN4 was immediately suspended pending the outcome of the investigation. There was evidence which showed the facility reported the initial allegation made by R3 to the SSA within two hours. There was no evidence in the investigative file which showed the results of the facility's investigation were submitted within five business days to the SSA. No abuse was substantiated, and LPN4 returned to the facility. 2. Review of R4's EMR titled Admission Record located under the Profile tab indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of left sided stroke. Review of a document provided by the facility titled Investigation Report, dated 07/05/23, indicated a family member reported on 07/03/23 that Certified Nursing Assistant (CNA) 3 was rough while providing R4 care while working on the 11:00 PM to 7:00 AM shift. The investigation revealed CNA3 was immediately suspended pending the outcome of the investigation. There was evidence which showed the facility reported the initial allegation made by R4's family member to the SSA within two hours. There was no evidence in the investigative file which showed the results of the facility's investigation were submitted within five business days to the SSA. No abuse was substantiated, and CNA3 returned to the facility. There were no clinical records which mentioned the allegations made by R4's family member on 07/03/23. Review of R4's EMR titled Care Plan located under the Care Plan tab, dated 08/02/23, indicated the resident had behaviors such as crying out loud and was accusatory. Review of R4's EMR titled admission MDS with an ARD of 12/12/23 and located under the MDS tab, indicated the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. The assessment revealed the resident had no behavioral concerns. Review of R4's EMR titled Nursing Clinical Evaluation, dated 01/15/24 and located under the Progress Notes tab, indicated the family member of the resident reported that the resident was afraid of CNA4 since the staff member allegedly spoke rudely to her and removed the call light from the resident. Review of a document provided by the facility titled Investigation Report, dated 01/23/24, indicated a family member reported on 01/15/24 that on 01/14/24, during the 11:00 PM to 7:00 AM shift, CNA4 spoke with R4 in an inappropriate manner and then took the resident's call light from her. The investigation revealed CNA4 was immediately suspended pending the outcome of the investigation. There was evidence which showed the facility reported the initial allegation made by R4's family member to the SSA within two hours. There was no evidence in the investigative file which showed the results of the facility's investigation were submitted within five business days to the SSA. No abuse was substantiated, and CNA4 returned to the facility. During an interview on 05/21/24 at 9:28 AM, the Director of Nursing (DON) stated she reported allegations of abuse to the SSA within two hours. The DON stated she submitted the five-day results of her investigations to the SSA by email but had no evidence to show that the five-day reports were submitted to the SSA. 3. Review of R5's EMR titled Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia and Alzheimer's disease. Review of R5's EMR titled Care Plan located under the Care Plan tab, dated 05/07/24, indicated the resident had a history of behaviors such as making false accusations of assault or missing money, yelling at staff and residents, cursing, and aggression toward other residents. Review of R5's EMR annual MDS with an ARD of 03/03/24 and located under the MDS tab, indicated the resident had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period. 4. Review of R6's EMR titled Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including lung cancer and dementia. Review of R6's EMR titled Care Plan located under the Care Plan tab, dated 06/08/23, indicated the resident had a history of behaviors such as using racial slurs, wandering, and cursing at residents. The care plan indicated R6 had severe memory impairment due to her diagnosis of dementia. The care plan indicated the resident was at high risk for experiencing abuse. Review of R6's EMR annual MDS with an ARD of 05/12/24 and located under the MDS tab, indicated the resident had a BIMS score of six out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period. Review of R5's Progress Notes, dated 08/14/23 and located in the EMR under the Progress Notes tab, revealed the resident was involved in a witnessed event during which the resident argued with R6 in the hallway, was separated from R6, and then ran back down the hallway toward R6 and hit R6 on her left shoulder three times. Review of a document provided by the facility titled Investigation Report, dated 08/16/23, indicated R5 and R6 were immediately separated, and an investigation was initiated related to the alleged abuse. The record indicated no injury to either resident related to the incident. There was evidence which showed the facility reported the initial allegation of physical abuse of R6 by R5 timely, however there was no evidence in the investigative file to show the results of the facility's investigation were submitted within five business days to the SSA. 5. Review of R9's EMR titled Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia and depression. Review of R9's EMR titled Care Plan located under the Care Plan tab, dated 10/04/23, indicated the resident had a history of experiencing hallucinations and delusions. The care plan indicated R9 was at high risk for experiencing abuse. Review of R9's quarterly MDS with an ARD of 05/11/24 and located in the EMR under the MDS tab, indicated the resident had a BIMS score of 14 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident experienced delusions during the assessment reference period. Review of R5's Progress Notes located in the EMR under the Progress Notes tab, indicated a second event, dated 09/09/23 during which R9 reported R5 entered her room and punched her on her left leg. The record indicated R5 stated she punched R9 on the leg because she thought someone had taken her money. Review of a document provided by the facility titled Investigation Report, dated 09/10/23, indicated R5 and R9 were immediately separated, and an investigation was initiated related to the alleged abuse. The record indicated no injury to either resident related to the incident. There was evidence which showed the facility reported the initial allegation of physical abuse of R9 by R5 timely, however there was no evidence in the investigative file to show the results of the facility's investigation were submitted within five business days to the SSA. 6. Review of R2's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included encephalopathy, pancytopenia, cerebral infarction, traumatic subdural hematoma, and seizures. Review of the Progress Notes from the EMR Progress Notes tab, showed on 06/21/23 at 10:36 PM, R2 had a fall at 8:40 PM with bleeding from the mouth and a dislodged tooth due to hitting her head on the floor. R2 was sent to the emergency room and admitted with subdural hematoma. Review of the facility provided investigation report to the State Agency revealed the top sheet of the Reportable Event Record/Report [aka AAS45] showed the date of event was 06/22/23 at 2:00 PM and today's date was documented as 06/24/23. The Investigation Form revealed On 06/21/23 resident [R2's name] was observed walking towards nursing station of unit 2b and falling on the floor. The last page in the file showed R2's representative was notified of the fall on 06/21/23 at 8:44 PM. Further review of the investigation file showed no evidence that the completed five-day investigation was provided to the State Agency. 7. Review of R11's Admission Record from the EMR Profile Tab showed a facility admitted [DATE] with medical diagnoses that included asthma, depression, anxiety, dementia, protein calorie malnutrition, cognitive communication deficit, and a language disorder. Review the Progress Notes from the EMR Progress Notes tab, showed on 10/23/23 at 5:05 PM that R11 was experiencing right lower extremity pain following a fall on 10/22/23. The medical practitioner was notified, and an X-ray was ordered. A review of the facility provided Reportable Event Record/Report [aka AAS45] showed the date of event from the top line of the report was 10/24/23 and the Today's Date was 10/25/23. Further review showed the X-ray report of the injury was received on 10/24/23. The investigation file did not show evidence of the completed five-day investigation report being provided to the State Agency. During an interview on 05/22/24 at 11:00 AM, the DON stated .the date of the event on the first page of the AAS45 is when I am first made aware [of the incident]. The date called in on the third page will match the date of the event on the first page, which is when I am made aware and will call it within two hours. When asked if there was any evidence or documentation that the completed five-day investigation was provided to the State Agency, the DON explained that the company deleted emails after 30 days, but she would contact the corporate office to see if there was any way of retrieving emails. At 11:45 AM, the DON stated the regional office advised her there was no way to retrieve the emails. At 12:07 PM, the DON confirmed that there was no evidence of the submission of the final investigation reports to the state agency. During an interview on 05/22/24 at 12:49 PM regarding the State Agency report investigations, the Administrator stated an expectation that We do reportable, and we do the investigation. As soon as we find something we call it in, within the time frame; the AAS45 is sent in which gives a brief summary and lists interventions. A full investigation is completed and sent [to the State Agency] upon request. The State does not always request a full investigation, but I think [DON's name] sends it in. 8. Review of a document titled the New Jersey Department of Health and Senior Services . Division of Health Facilities Evaluation and Licensing .Reportable Event Record/Report, dated 09/11/23 revealed on 09/08/23 at 9:00 AM, R7 reported he was not receiving his breakfast and care prior to dialysis on Tuesday, Thursday, and Saturday. According to this report, the State Agency (SA) was notified of the allegation on 09/08/23 at 10:30 AM. Review of the Investigation Form signed by the Director of Nursing (DON) with a signature date of 09/10/23, revealed the investigation was complete. There was no evidence in the report or in the investigation documentation to show the report was submitted to the SA within five days after the initial report. During an interview on 05/22/24 at 12:51 PM, the DON verified she did not have any evidence to show she submitted the result of the investigation to the SA. 9. Review of a document titled the New Jersey Department of Health and Senior Services . Division of Health Facilities Evaluation and Licensing .Reportable Event Record/Report, dated 10/19/23 revealed on 10/16/23 at 3:00 PM, R31 stated a nurse on the 11:00 PM to 7:00 AM shift made a verbally aggressive comment to her. Review of the report revealed the SA was notified of the alleged abuse on 10/16/23 at 4:00 PM, one hour after R31 made the allegation. Review of the Investigation Form signed by the DON with a signature date of 10/18/23, revealed the investigation was complete and the verbal abuse could not be substantiated. The investigation report and its attachments did not show that the results of the investigation were sent to the SA within five days after the allegation was received. During an interview on 05/22/24 at 12:51 PM, the DON verified she did not have any evidence to show she submitted the result of the investigation to the SA. 10. Review of the New Jersey Department of Health and Senior Services .Division of Health Facilities Evaluation and Licensing .Reportable Event Record/Report, dated 02/13/24 with an event date of 02/12/24 at 4:00 PM and completed by the DON revealed staff to resident abuse was alleged. According to the report facility staff was made aware on 02/12/24 by the Ombudsman's office that Resident 14's wife alleged R14 was spoken to in an inappropriate manner by a Certified Nursing Assistant. The family member was unable to provide specific dates. The initial report was made to the State Agency on 02/12/24 at 4:19 PM within an hour of finding out about the allegation from the Ombudsman. Review of the Investigation form, signed by the DON with signature date of 02/19/24, revealed the investigation was complete. The investigation report and its attachments lacked evidence to support that the results of the investigation were sent to the SA within five days after the allegation was received. During an interview on 05/22/24 at 12:51 PM, the DON verified she did not have any evidence to show she submitted the result of the investigation to the SA. Review of the facility's policy titled, Abuse, dated 12/22 and provided by the facility, indicated .The facility prohibits the mistreatment, neglect, and abuse of residents/patients. which strives to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property .The Administrator and Director of Nursing are responsible for investigation and reporting .Report results of investigation to the proper authorities as required by State law . There was no information in the policy which directed the facility to submit the results of their investigation to the State Survey Agency (SSA) within five business days. NJAC 8:39-9.4(e) 18947 28154

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) properly store and secure medications and properly label opened multidose medications and b.) properly secure wound treatment carts when not attended. This deficient practice was observed in a.) 2 of 2 medication storage rooms and 4 of 4 medication carts on 4 of 4 nursing units reviewed for medication storage and labeling and in b.) 1 of 1 treatment carts observed during wound observation. This was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 a.) On 02/28/2024 at 9:39 AM, the surveyor, in the presence of a second state surveyor and a federal surveyor, interviewed Registered Nurse/Unit Manager (RN/UM #1), who stated all nurses are responsible to maintain the medication storage room's organization and cleanliness. She added that there should be no open medication containers in the storage room and any multidose medications that are stored in the medication room or refrigerator should be labeled and dated with the date opened. The RN/UM1 stated the medication refrigerator temperature is checked daily on the 11 PM nursing shift to ensure proper temperatures are maintained for refrigerated medications. At this point the surveyor, in the presence of the second state surveyor, federal surveyor, and RN/UM #1, reviewed the first floor's medication storage room. The following was observed: 1. One opened multi-dose vial of tuberculin purified protein derivative (an injectable medication used to test for tuberculosis infection) stored in the refrigerator and undated with the date it was opened. To which the RN/UM #1 confirmed should have been dated. 2. One opened bottle of ibuprofen 200 milligram (mg) tablets (medication used for pain) dated with opened date 1/28 and stored with unopened medication bottles. To which the RN/UM #1 stated it should not be in the medication room, rather in the medication cart. 3. Two opened boxes of bisacodyl 10 mg laxative suppository 12 count, each box containing eight (8) and undated. 4. One large clear plastic, resealable bag with a pharmacy prescription label which indicated which resident the contents were prescribed and contained three cefapime (antibiotic) 2-gram (g) vials prescribed for a different resident. To this the RN/UM #1 stated she was unsure why these medications were stored that way and should be returned to the pharmacy. Further review of the February 2024 medication refrigerator temperature monitoring log indicated the following temperatures in degrees Fahrenheit (F): 2/1: 33 2/2: 34 2/4: 35 2/6: 31 2/7: 35 2/8: 35 2/9: 33 2/10: 31 2/11: 32 2/12: 31 2/13: 33 2/15: 35 2/18: 32 2/19: 34 2/20: 33 2/21: 30 2/22: 30 2/23: 29 2/24: 27 2/25: 28 2/26: 27 2/27: 29 On 02/28/2024 at 10:25 AM, the surveyor, in the presence of a second state surveyor interviewed RN/UM #2, who stated everyone with access to the medication storage room, including nurses, are responsible to maintain the medication storage room's organization and cleanliness. He confirmed that there should be no open medication containers in the storage room and any multidose medications that are stored in the medication room or refrigerator should be labeled and dated with the date opened. The RN/UM #2 stated the medication refrigerator temperature is checked daily on the 11 PM - 7 AM nursing shift to ensure proper temperatures are maintained for refrigerated medications and verified by the unit manager on the 7 AM - 3 PM shift. At this point the surveyor, in the presence of the second state surveyor and RN/UM #2, reviewed the first floor's medication storage room. The following was observed: 1. One expired 1000 milliliter (ml) bag of 0.9% sodium chloride (normal saline) intravenous (IV) solution with expiration date October 2023 2. One opened multi-dose vial of Novolog 100 units/ml insulin stored in the medication refrigerator labeled with an opened date of 10/16. The RN/UM2 confirmed this was opened and dated on 10/16/23 and is good for 28 days after opening and should have been discarded. Further review of the February 2024 medication refrigerator temperature monitoring log indicated the following temperatures in degrees Fahrenheit (F): 2/1: 30 2/2: 30 2/3: 30 2/4: 30 2/5: 29 2/6: 30 2/7: 30 2/8: 31 2/9: 30 2/10: 30 2/11: 30 2/12: 30 2/13: 30 2/14: 30 2/16: 30 2/17: 30 2/18: 30 2/19: 30 2/20: 29 2/21: 32 2/22: 32 2/23: 32 2/24: 32 2/25: 30 2/26: 30 2/27: 30 On 02/28/2024 at 11:00 AM, in the presence of a second state surveyor and a federal surveyor, interviewed the Licensed Practical Nurse (LPN #4) who stated nurses assigned to the medication cart are responsible for the organization and cleanliness of the cart. She further stated there should be no loose pills in the drawers, and all medications should be labeled and dated once opened, including multi-dose medications such as vials and inhalers should be labeled and dated on the vial, bottle, or device containing the medication. At this point the surveyor, along with LPN #4, reviewed nursing unit 1A's medication cart 1A - back. The following was observed: 1. Eight (8) loose pills of various shapes, colors, and sizes. 2. One opened vial of Lantus 100 unit/ml insulin undated. 3. One Lispro U-100 insulin vial opened and undated. 4. One opened fluticasone propionate (nasal spray) 0.54 fluid ounce bottle undated 5. One gentamicin solution 0.3% ophthalmic (eye drops) opened and undated 6. One Incruse umeclidinium inhalation powder 62.5 microgram (mcg) (medication used to treat lung disease) inhaler opened and undated. 7. One budesonide and formoterol fumarate dihydrate inhalation aerosol 160/4.5 (medication used to treat lung disease) inhaler opened and not dated or labeled. On 02/28/2024 at 11:41 AM, in the presence of a second state surveyor, the surveyor interviewed LPN #3, who confirmed that opened multi-dose medications should be labeled with resident's name and dated with opened date, and there should be no loose pills in the cart drawers. At this point the surveyor along with LPN #3 reviewed nursing unit 1C's medication cart. The following was observed: 1. Four (4) loose pills of various shapes, colors, and sizes. 2. One fluticasone propionate/salmeterol discus inhalation powder 100 mcg/50 mcg inhaler (medication to treat lung disease) opened and not dated. 3. One fluticasone propionate/salmeterol discus inhalation powder 500 mcg/50 mcg inhaler opened and not dated. 4. One budesonide and formoterol fumarate dihydrate inhalation aerosol 80 mcg/4.5 mcg inhaler opened and not dated or labeled. 5. One fluticasone propionate (nasal spray) 15.8 ml bottle opened and not dated or labeled. 6. One Systane solution (eye drops) bottle opened not labeled or dated. 7. One Systane solution bottle opened not dated. 8. One olopatadine hydrochloride ophthalmic solution 0.2% (eye drops) opened and not dated. 9. One carboxymethylcellulose sodium ophthalmic solution 0.5% (eye drops) opened bottle not dated. Once the surveyor completed review of the medication cart, LPN #3 stated she would discard of the loose pills in the sharps container (a plastic container attached to the side of the medication cart, used to dispose of potentially sharp medical equipment). When the surveyor questioned that action, LPN #3 stated she was not sure where to discard and would ask the unit manager. On 02/28/2024 at 12:29 PM, in the presence of a second state surveyor, the surveyor interviewed LPN #1, who also confirmed that medication containers and vials should be labeled and dated once opened. At this point the surveyor along with LPN #1 reviewed nursing unit 2A's medication cart. The following was observed: 1. One Anoro Ellipta inhalation powder inhaler (medication used to treat lung disease) opened and not dated. 2. One box of albuterol sulfate inhalation solution 0.083% 2.5 mg/ 3 ml (medication used to treat lung disease) which contained one opened and undated foil pouch containing 23 single use vials. 3. One Incurse Ellipta 62.5 mcg inhalation powder inhaler (medication used to treat lung disease) opened and not labeled or dated. 4. One Ventolin HFA 90 mcg inhaler (medication used to treat lung disease) opened and not labeled or dated. On 02/28/2024 at 1:01 PM, in the presence of a second state surveyor, the surveyor interviewed LPN #2, who stated that there should be no loose pills in the carts and that opened multi-dose medications should be labeled and dated once opened. At this point the surveyor along with LPN #2 reviewed nursing unit 2D's medication cart. The following was observed: 1. 15 loose pills of various colors, shapes, and sizes. 2. One fluticasone propionate (nasal spray) opened and not dated. 3. One box of ipratropium bromide 0.5 mg and albuterol sulfate 3 mg (medication used to treat lung disease) containing one opened and undated foil pouch with four single dose vials. On 02/28/2024 at 01:55 PM, the surveyor, in the presence of a second state surveyor, interviewed the Director of Nursing (DON) who stated, that expired medications should be removed immediately from medication storage areas, medication refrigerator temperatures should be maintained between 34- and 46-degrees F and that temperatures outside the acceptable range could compromise the efficacy of the medication and could have negative effects for residents. The DON further stated that opened medication bottles should not be stored in the medication storage rooms, once opened, multi-use medications, whether inhalers, insulin, or otherwise, should be labeled and dated with the date opened and preferably the resident's name, stored appropriately, and discarded after 30 days of opening. Furthermore, the DON included that medications should always be disposed of appropriately in the drug buster bottle and not in the sharps container. On 02/29/2024 at 12:30 PM, the surveyor, in the presence of a federal surveyor, interviewed the facility's pharmacy consultant pharmacist (RPh) by telephone, who stated multi-dose medications are good for 30 days after opening unless it is insulin, which expires 28 days after opening. The RPh stated the insulin vial dated as being opened 10/16 should have been discarded. She further confirmed that best practice would be to label and date the medication device, bottle, inhaler, or vial itself once opened with the resident's name and date opened in case the medication and its box were to be separated. She stated refrigerated medications should be stored between 36- and 46-degrees F, and if not could affect the medication's potency. She stated medication refrigerator temperatures should be checked at least once a day to maintain appropriate temperature storage. She further included that medications should not be disposed of in the sharps container or flushed, rather in the medication drug buster or biohazard waste container, depending on the medication. b.) On 02/29/2024 at 2:14 PM, the surveyor observed LPN #2 on the second-floor nursing unit 2D prepare a wound care treatment cart for use by the nurses' station. She had the cart unlocked when she was approached by a resident in a wheelchair. LPN2 then walked away from the treatment cart to assist the resident back to their room, leaving the cart unlocked. The surveyor observed the unlocked cart and other nursing staff members walk past the unlocked cart a total of six times without acknowledging the cart not being secured. The surveyor did not observe any residents come near the treatment cart during this time, however there were seven residents around the nursing station in geriatric chairs and wheelchairs. At 2:24 PM, once LPN #2 returned to the treatment cart, the surveyor asked about the unlocked cart, to which the LPN #2 acknowledged it was left unlocked stating, I know its unlocked, I don't have a key for it that's why I left it. LPN #2 confirmed there were medications stored in the cart and should not have left it unlocked unattended. On 02/29/2024 at 2:35 PM, the surveyor, in the presence of a federal surveyor, observed LPN #2 preparing wound care supplies from the treatment cart by a resident's room in the 2D nursing unit hallway. LPN #2 walked away from the treatment cart to obtain gloves from the glove dispenser on the wall and perform hand hygiene with alcohol based hand sanitizer, leaving the treatment cart unlocked. On 03/01/2024 at 1:41 PM, the surveyor, in the presence of a federal surveyor, interviewed the Director of Nursing (DON), who stated the expectation is for medication and treatment carts are to be locked when not attended by the nursing staff. She stated treatment carts contain medications for wound and other care and leaving them unlocked could risk residents being able to access their contents. A review of the facility's Medication Storage policy with a last revised date of 12/2023, under the section titled policy, included but was not limited to, to provide guidelines for proper storage of medications within the facility. this center will have medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with department of health guidelines. The section titled procedure included, medications will be stored in an orderly, organized manner in a clean area . medications will be stored in the original labeled containers received from the pharmacy. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. Medication requiring refrigeration will be stored in a refrigerator that is maintained between 2 to 8 degrees Celsius (36 to 46 degrees F) . temperature will be checked daily to ensure it is within the specified range. If temperature is out of range, the refrigerator thermostat will be adjusted. A review of the facility's Medication Administration policy with revised date 12/2023, included but was not limited to, the expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date shall be recorded on the container . during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide . the cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. A review of the facility's Multi-Dose Vials policy with revised date 12/2022 included but was not limited to, if a multi-dose vial has been opened or accessed (e.g., needle punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter) date . Review of the facility's Narcotic Destruction policy with revised date 9/2023, included but was not limited to, soiled, damaged, expired drugs, discontinued controlled drugs, oral solid medications, and liquids can be destroyed using drug buster/RX Destroyer disposal system. N.J.A.C. 8:39-29.4

Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the narcotic Shift Count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications. This deficient practice was identified on 4 of 4 medication carts observed on 4 of 4 nursing units and was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 On 2/28/2024 at 11:00 AM, the surveyor, in the presence of a second state surveyor and a federal surveyor, interviewed Licensed Practical Nurse (LPN #4), who stated nurses coming on duty along with the nurse going off duty are to count the narcotics in the medication cart together and sign the Shift Count log together to confirm the count is accurate and narcotics are accounted for. She confirmed there should be no missing documentation or blank sections for each shift change. At this point the surveyor, along with LPN #4, reviewed the medication cart and narcotic logs as well as the shift count logs for nursing unit 1A medication cart 1A - back. The following was observed: 1. 02/05/2024: 11 PM and 2/15/24: 11 PM shift count was not documented. 2. The columns labeled EDK box sealed? and is count correct? were blank for 2/7/24: 7 AM and 2/23/24: 7 AM. 3. Coming on duty nurse's signature was missing for 2/9/24: 11 PM 4. Going off duty Nurse's signature was missing for 2/27/24: 7 AM On 02/28/2024 at 11:41 AM, in the presence of a second state surveyor, the surveyor interviewed LPN #3, who confirmed that narcotic shift count logs are to be completed by the incoming and outgoing nurses, together upon reconciling the medication cart's narcotics at the change of each shift and should not be pre-signed or completed. She further stated that declining inventory logs (logs to account for individual narcotics for each resident) are to be completed for each dose of that medication, immediately once it has been dispensed from its packaging prior to administering it to the resident. At this point the surveyor along with LPN #3 reviewed nursing unit 1C's medication cart and narcotic logs. The following was observed on the Shift Count log: 1. The columns labeled EDK box sealed? and is count correct? were blank for 2/4/24: 3 PM, 2/11: 7 AM, 2/11: 3 PM, 2/18: 7 AM, 2/21: 3 PM, 2/25: 7 AM, 3 PM, and 11 PM. 2. Coming on duty nurse's signature was missing for 2/12: 11 PM 3. Going off duty Nurse's signature was missing for 2/21: 11 PM 4. 2/24: 11 PM shift count was not documented. 5. 2/28: 3 PM going off duty nurse's signature and EDK box sealed? and is count correct? columns were pre-filled and pre-signed. The following narcotic medications and doses were signed in the medication administration record (MAR) as being administered, but not documented as being dispensed in their corresponding declining inventory logs: 1. Resident #29's diazepam 5 milligram (mg) (a medication used to treat anxiety) 2/28/24: 7-10 AM. 2. Resident #44's tramadol 50 mg (a medication used to treat pain) 2/28/24: 9 AM. 3. Resident #82's tramadol 50 mg 2/28/24: 9 AM. 4. Resident #148's lacosamide 150 mg (a medication used to treat seizures) 2/28/24: 9 AM. On 02/28/2024 at 12:29 PM, in the presence of a second state surveyor, the surveyor interviewed LPN #1, who confirmed that narcotic shift count logs are to be completed by the incoming and outgoing nurses, together upon reconciling the medication cart's narcotics at the change of each shift and acknowledged that if it's not documented it's not done. At this point the surveyor along with LPN #1 reviewed nursing unit 2A's medication cart and narcotic logs. The following was observed on the Shift Count log: 1. Going off duty Nurse's signature was missing for 2/4: 11 PM, 2/5: 7 AM, 2/9: 11 PM, 2/12: 11 PM, 2/13: 11 PM, 2/14: 7 AM, 2. Coming on duty nurse's signature was missing for 2/6: 11 PM, 2/9: 11 PM, 2/13: 3 PM, 2/27: 7 AM. 3. The columns labeled EDK box sealed? and is count correct? were blank for 2/7: 11 PM, 2/9: 11 PM, 2/13: 11 PM, 2/14: 7 AM, 2/18: 11 PM, 2/21: 3 PM, 2/22: 7 AM, 3 PM, 2/27: 7 AM. 4. 2/27: 3 PM, and 2/28: 7 AM shift counts were not documented. On 02/28/2024 at 1:01 PM, in the presence of a second state surveyor, the surveyor interviewed LPN #2, who confirmed that narcotic shift count logs are to be completed by the incoming and outgoing nurses, together upon reconciling the medication cart's narcotics at the change of each shift and there should be no missing documentation. At this point the surveyor along with LPN #2 reviewed nursing unit 2D's medication cart and narcotic logs. The following was observed on the Shift Count log: 1. Going off duty Nurse's signature was missing for 12/23/23: 11 PM, and 2/20/24: 11 PM. 2. Coming on duty nurse's signature was missing for 12/23/23: 3 PM, and 2/28/24: 7 AM. 3. 2/28: 3 PM going off duty nurse's signature was pre-signed. On 02/28/2024 at 1:55 PM, the surveyor, in the presence of a second state surveyor, interviewed the Director of Nursing who stated, that the expectation is that the nursing unit managers are to check the narcotic logs daily to ensure the signing in and out of narcotics and shift to shift reconciliation logs are being completed. She further stated there should be no missing documentation at all and the purpose of the narcotic logs is to maintain accountability of the controlled medications. She confirmed there should be no pre-signed signatures for end of shift, and declining inventory logs should be filled out immediately once the medication dose is dispensed from the packaging. On 02/29/2024 at 12:30 PM, the surveyor, in the presence of a federal surveyor, interviewed the facility's pharmacy consultant pharmacist (RPh) by telephone, who stated narcotic logs should not have blanks or dots, and declining inventory logs should be completed immediately once the medication is poured or dispensed, not at the end of pass. Review of the facility's Controlled Substance Management policy with a last revised date of 8/2023 included but was not limited to, 2. Separate records shall be maintained on all controlled substances in the form of a declining inventory record. Such record shall be accurately maintained and shall include. a. the name of the resident. b. the name of the prescriber c. the prescription numbers d. the drug names e. the form of the medication f. the strength of the medication g. the strength of the dose administered. h. the date and time of administration i. the signature of the person administering the drug. 3. Such records shall be reconciled by the incoming and outgoing nurse. Two nurses must count the remaining medication at each shift, and any handoff of narcotic keys . The section titled accounting procedures further included, 1. All controlled substances shall be counted at the change of each shift by the incoming and outgoing nurse. NJAC 8:39-29.7(c)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: Repeat deficiency from recertification survey of [DATE] On [DATE] from 9:32 AM to 10:21 AM, the surveyors, accompanied the Director of Food Services (DOFS), observed the following in the kitchen: The surveyors observed a dietary aide (DA) in the kitchen. The DA had lengthy braids to mid shoulder and was observed wearing a baseball style hat. The braids extended past the shoulders and were exposed. The DA did not have a hair net in place and the hair was exposed. In the dry storage room, a can of corn on the 4 wheeled mobile can rack had a significant dent and a can of artichokes on a shelf had a significant dent on the seam. On interview the DOFS agreed that the cans should have been placed in the designated dented can area, In the dessert and juice refrigerator the surveyors observed (5) trays of portioned controlled, in house poured juices designated for resident use. The juices had no dates. The DOFS was asked if they should be labeled according to facility policy. The DOFS replied, Yes. In the walk-in freezer the surveyors observed (3) bags of unopened cauliflower and 1 bag of unopened yellow squash that had been removed from their original container. The cauliflower and squash had no dates. In the walk-in refrigerator the surveyors observed (7) bags of unopened lettuce on various shelves with a manufacturer's best if used by date of [DATE]. The DOFS stated, We just got them in, they must have come in that way. When asked who was responsible for checking the food in, the DOFS stated, We are. In the prep refrigerator, the surveyors observed an unopened bag of lettuce with a best if used by date of [DATE], and an unopened bag of tortillas labeled received ,d+[DATE] and use by [DATE]. The surveyors observed (2) air conditioners in the food prep area near the tray line. A finger swipe by the surveyor determined that the vents of the air conditioners were covered with a black, dust-like substance. When asked when they were last cleaned the DOFS replied, Every two weeks, it is on the cleaning schedule, and we haven't turned it on in two months. On [DATE] from 10:56 AM to 11:28 AM, the surveyors, accompanied by the DOFS, observed the following during a follow up visit to the kitchen: In the walk-in refrigerator the surveyors observed approximately ,d+[DATE] stacks of plastic crates which contained juices and milk. The ,d+[DATE] bottom crates were stored directly on the floor of the refrigerator and did meet the 6-inch requirement for food to be stored off the floor. The surveyors observed the electrical outlet box behind the coffee machine and adjacent to the counter of the hot food holding/prep area. The box was covered in unidentified brown/grease-like debris. The backsplash of the coffee station was also covered in brown unidentified debris, as well as the water supply line. At 11:06 AM, the surveyor observed a kitchen staff at the designated handwashing sink. Upon completion of hand-hygiene the staff attempted to grab a hand towel, however, the hand towel dispenser was empty. The staff walked to the dish washing room to obtain a hand towel at the designated hand washing sink. The hand towel dispenser was also empty. When asked who was responsible for ensuring that hand towels were sufficiently stocked, staff stated that the housekeeping department was responsible for stocking the hand towel dispensers. On [DATE] at 01:49 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator agreed, all foods should be labeled, there should be no expired food in kitchen, and hair nets should be worn to encompass all the hair. A review of facility provided policy titled USE BY DATE POLICY, last reviewed on [DATE] revealed under POLICY: All food items that are thawed, prepared or removed from their original container will have an expiration date or use by date: To ensure the freshness of all items being served; To provide a universal system of identification of expiration dates. It was also revealed under PROCEDURE: 2. All kitchen staff will be in serviced on labeling procedures and 4. All items sent to floors and taken out of original containers, will have an expiration/ use by date. A review of the facility provided policy titled PERSONAL HYGIENE POLICY, last revised on ,d+[DATE] revealed the following under POLICY: All employees are required to follow acceptable personal hygiene practices to ensure that food is prepared, stored, and distributed in safe and sanitary manner, preventing the spread of food borne illness. It was also revealed under the heading PROCEDURE: 4. Employees must wear hair nets and beard restraint required by local and federal health codes. No hair ornaments are permitted unless function as hair restraint. The surveyor reviewed the facility policy titled Food Safety-Food Handling Policy; last date revised: ,d+[DATE]. The following was revealed under the heading POLICY: Food will be stored prepared, handled and served so that the risk of foodborne illness is minimized. The following was revealed under the heading PROCEDURE: 7. All kitchen staff will be in serviced on labeling procedures. All prepared items stored in cooling units will be labeled and dated.A review of an undated facility provided kitchen cleaning schedule titled Nutrition Services Cleaning Responsibilities and Schedule did not reveal any Cleaning Duty for the (2) air conditioners. A Cleaning Duty for the Tea and Coffee Machine revealed it was to be cleaned daily by the AM aide. N.J.A.C. 18:,d+[DATE].2(g) 49712

C/O # NJ171057 Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure to have sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by following: On 02/28/2024 at 10:30 AM surveyor #2 held a resident council meeting with 10 to 11 residents. Regarding the call bells, all in the group said the wait time was from 2 hours to 4.5 hours waiting for call bell to be answered, especially on evenings and night shift. They further stated, weekends horrible. 5 of 5 residents stated the delay in call bell response time caused a fall or incontinence episode. On 02/28/2024 at 12:05 PM surveyor #2 met with Resident #171 who stated that he/she constantly hears people calling for help. Resident #171 further stated that he/she hears call bells ringing for long periods of time. He/she thinks that staffing is a problem, and nobody wants to work at the facility. Resident #171 further stated his/her opinion is that the staff is overwhelmed and understaffed and that nurses are always doing doubles. 1. For the week of Complaint staffing from 03/12/2023 to 03/18/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in total staff for residents on 1 of 7 evening shifts as follows: -03/12/23 had 11 CNAs for 189 residents on the day shift, required at least 24 CNAs. -03/12/23 had 17 total staff for 189 residents on the evening shift, required at least 19 total staff. -03/13/23 had 13 CNAs for 189 residents on the day shift, required at least 24 CNAs. -03/14/23 had 21 CNAs for 189 residents on the day shift, required at least 24 CNAs. -03/15/23 had 20 CNAs for 189 residents on the day shift, required at least 24 CNAs. -03/16/23 had 23 CNAs for 189 residents on the day shift, required at least 24 CNAs. -03/17/23 had 19 CNAs for 189 residents on the day shift, required at least 24 CNAs. -03/18/23 had 17 CNAs for 194 residents on the day shift, required at least 24 CNAs. 2. For the week of Complaint staffing from 11/12/2023 to 11/18/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts, deficient in total staff for residents on 2 of 7 evening shifts, and deficient in total staff for residents on 2 of 7 overnight shifts as follows: -11/12/23 had 9 CNAs for 199 residents on the day shift, required at least 25 CNAs. -11/12/23 had 18 total staff for 199 residents on the evening shift, required at least 20 total staff. -11/13/23 had 18 CNAs for 199 residents on the day shift, required at least 25 CNAs. -11/14/23 had 21 CNAs for 199 residents on the day shift, required at least 25 CNAs. -11/15/23 had 24 CNAs for 199 residents on the day shift, required at least 25 CNAs. -11/15/23 had 13 total staff for 199 residents on the overnight shift, required at least 14 total staff. -11/16/23 had 19 CNAs for 199 residents on the day shift, required at least 25 CNAs. -11/17/23 had 21 CNAs for 199 residents on the day shift, required at least 25 CNAs. -11/18/23 had 18 CNAs for 199 residents on the day shift, required at least 25 CNAs. -11/18/23 had 18 total staff for 199 residents on the evening shift, required at least 20 total staff. -11/18/23 had 13 total staff for 199 residents on the overnight shift, required at least 14 total staff. 3. For the week of Complaint staffing from 12/10/2023 to 12/16/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts, deficient in total staff for residents on 2 of 7 evening shifts, deficient in CNAs to total staff on 1 of 7 evening shifts, and deficient in total staff for residents on 6 of 7 overnight shifts as follows: -12/10/23 had 12 CNAs for 198 residents on the day shift, required at least 25 CNAs. -12/10/23 had 16 total staff for 198 residents on the evening shift, required at least 20 total staff. -12/10/23 had 7 CNAs to 16 total staff on the evening shift, required at least 8 CNAs. -12/10/23 had 13 total staff for 198 residents on the overnight shift, required at least 14 total staff. -12/11/23 had 16 CNAs for 198 residents on the day shift, required at least 25 CNAs. -12/12/23 had 15 CNAs for 198 residents on the day shift, required at least 25 CNAs. -12/12/23 had 13 total staff for 198 residents on the overnight shift, required at least 14 total staff. -12/13/23 had 23 CNAs for 198 residents on the day shift, required at least 25 CNAs. -12/13/23 had 11 total staff for 198 residents on the overnight shift, required at least 14 total staff. -12/14/23 had 22 CNAs for 198 residents on the day shift, required at least 25 CNAs. -12/14/23 had 13 total staff for 198 residents on the overnight shift, required at least 14 total staff. -12/15/23 had 19 CNAs for 199 residents on the day shift, required at least 25 CNAs. -12/15/23 had 19 total staff for 199 residents on the evening shift, required at least 20 total staff. -12/15/23 had 12 total staff for 199 residents on the overnight shift, required at least 14 total staff. -12/16/23 had 18 CNAs for 199 residents on the day shift, required at least 25 CNAs. -12/16/23 had 11 total staff for 199 residents on the overnight shift, required at least 14 total staff. 4. For the 3 weeks of Complaint staffing from 01/21/2024 to 02/10/2024, the facility was deficient in CNA staffing for residents on 14 of 21 day shifts, deficient in total staff for residents on 2 of 21 evening shifts, deficient in CNAs to total staff on 1 of 21 evening shifts, and deficient in total staff for residents on 12 of 21 overnight shifts as follows: -01/21/24 had 12 CNAs for 190 residents on the day shift, required at least 24 CNAs. -01/21/24 had 13 total staff for 190 residents on the overnight shift, required at least 14 total staff. -01/22/24 had 11 CNAs for 190 residents on the day shift, required at least 24 CNAs. -01/22/24 had 9 CNAs to 21 total staff on the evening shift, required at least 10 CNAs. -01/22/24 had 12 total staff for 190 residents on the overnight shift, required at least 14 total staff. -01/23/24 had 16 CNAs for 190 residents on the day shift, required at least 24 CNAs. -01/24/24 had 22 CNAs for 190 residents on the day shift, required at least 24 CNAs. -01/25/24 had 22 CNAs for 192 residents on the day shift, required at least 24 CNAs. -01/25/24 had 12 total staff for 192 residents on the overnight shift, required at least 14 total staff. -01/26/24 had 20 CNAs for 189 residents on the day shift, required at least 24 CNAs. -01/26/24 had 11 total staff for 189 residents on the overnight shift, required at least 13 total staff. -01/27/24 had 22 CNAs for 189 residents on the day shift, required at least 24 CNAs. -01/28/24 had 8 CNAs for 188 residents on the day shift, required at least 23 CNAs. -01/28/24 had 9 total staff for 188 residents on the overnight shift, required at least 13 total staff. -01/29/24 had 12 CNAs for 188 residents on the day shift, required at least 23 CNAs. -01/29/24 had 11 total staff for 188 residents on the overnight shift, required at least 13 total staff. -01/30/24 had 16 CNAs for 188 residents on the day shift, required at least 23 CNAs. -01/30/24 had 11 total staff for 188 residents on the overnight shift, required at least 13 total staff. -02/01/24 had 13 total staff for 192 residents on the overnight shift, required at least 14 total staff. -02/03/24 had 19 CNAs for 192 residents on the day shift, required at least 24 CNAs. -02/03/24 had 11 total staff for 192 residents on the overnight shift, required at least 14 total staff. -02/04/24 had 12 CNAs for 192 residents on the day shift, required at least 24 CNAs. -02/04/24 had 17 total staff for 192 residents on the evening shift, required at least 19 total staff. -02/04/24 had 11 total staff for 192 residents on the overnight shift, required at least 14 total staff. -02/05/24 had 16 CNAs for 192 residents on the day shift, required at least 24 CNAs. -02/06/24 had 18 CNAs for 191 residents on the day shift, required at least 24 CNAs. -02/08/24 had 16 CNAs for 189 residents on the day shift, required at least 24 CNAs. -02/09/24 had 17 CNAs for 189 residents on the day shift, required at least 24 CNAs. -02/09/24 had 12 total staff for 189 residents on the overnight shift, required at least 13 total staff. -02/10/24 had 12 CNAs for 189 residents on the day shift, required at least 24 CNAs. -02/10/24 had 18 total staff for 189 residents on the evening shift, required at least 19 total staff. -02/10/24 had 10 total staff for 189 residents on the overnight shift, required at least 13 total staff. 5. For the 2 weeks of staffing prior to survey from 02/11/2024 to 02/24/24, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts, deficient in total staff for residents on 3 of 14 evening shifts, deficient in CNAs to total staff on 2 of 14 evening shifts, and deficient in total staff for residents on 12 of 14 overnight shifts as follows: 02/11/24 had 14 CNAs for 189 residents on the day shift, required at least 24 CNAs. -02/11/24 had 18 total staff for 189 residents on the evening shift, required at least 19 total staff. -02/11/24 had 10 total staff for 189 residents on the overnight shift, required at least 13 total staff. -02/12/24 had 15 CNAs for 188 residents on the day shift, required at least 23 CNAs. -02/13/24 had 22 CNAs for 188 residents on the day shift, required at least 23 CNAs. -02/13/24 had 12 total staff for 188 residents on the overnight shift, required at least 13 total staff. -02/14/24 had 22 CNAs for 188 residents on the day shift, required at least 23 CNAs. -02/15/24 had 19 CNAs for 188 residents on the day shift, required at least 23 CNAs. -02/15/24 had 12 total staff for 188 residents on the overnight shift, required at least 13 total staff. -02/16/24 had 21 CNAs for 195 residents on the day shift, required at least 24 CNAs. -02/16/24 had 12 total staff for 195 residents on the overnight shift, required at least 14 total staff. -02/17/24 had 15 CNAs for 195 residents on the day shift, required at least 24 CNAs. -02/17/24 had 11 total staff for 195 residents on the overnight shift, required at least 14 total staff. -02/18/24 had 12 CNAs for 195 residents on the day shift, required at least 24 CNAs. -02/18/24 had 12 total staff for 195 residents on the overnight shift, required at least 14 total staff. -02/19/24 had 18 CNAs for 195 residents on the day shift, required at least 24 CNAs. -02/19/24 had 12 total staff for 195 residents on the overnight shift, required at least 14 total staff. -02/20/24 had 13 CNAs for 195 residents on the day shift, required at least 24 CNAs. -02/20/24 had 10 total staff for 195 residents on the day shift, required at least 14 total staff. -02/21/24 had 19 CNAs for 195 residents on the day shift, required at least 24 CNAs. -02/21/24 had 8 CNAs to 19 total staff on the evening shift, required at least 9 CNAs. -02/21/24 had 12 total staff for 195 residents on the overnight shift, required at least 14 total staff. -02/22/24 had 20 CNAs for 195 residents on the day shift, required at least 24 CNAs. -02/22/24 had 18 total staff for 195 residents on the evening shift, required at least 19 total staff. -02/22/24 had 12 total staff for 195 residents on the overnight shift, required at least 14 total staff. -02/23/24 had 19 CNAs for 207 residents on the day shift, required at least 26 CNAs. -02/23/24 had 10 CNAs to 22 total staff on the evening shift, required at least 11 CNAs. -02/23/24 had 11 total staff for 207 residents on the overnight shift, required at least 15 total staff. -02/24/24 had 11 CNAs for 207 residents on the day shift, required at least 26 CNAs. -02/24/24 had 19 total staff for 207 residents on the evening shift, required at least 21 total staff. -02/24/24 had 9 total staff doe 207 residents on the overnight shift, required at least 15 total staff. On 03/04/2024 at 10:47 AM, the surveyor interviewed the staffing coordinator who stated that the CNA ratios are of 1 to 8 on day shift, 1 to 10 on evening shift, and 1 to 14 on night shift. She also stated that one LPN on each hall is ideal for 7-3 and 3-11 shifts. She further stated the facility has a 3-11 supervisor Monday through Friday and that day shift has Unit Managers also Monday through Friday. She also stated that on the 11-7 shift they staff four nurses (2 upstairs and 2 downstairs) and a RN supervisor. On 03/05/2024 at 09:28 AM, the surveyor interviewed the Director of Nursing regarding minimum staffing. She stated that the facility is separated into 4 units, 1A/1B, 1C/1D, 2A/2B, and 2C/2D. During the day shift Monday through Friday there should be eight to nine nurses in addition to four unit managers, on the evening shift eight nurses plus one supervisor, and on the night shift four nurses plus one supervisor. On the weekend day shift there should be eight nurses and one supervisor. She also stated that there should be four CNAs on each unit on each shift. She also stated that the shortage is all over and the management staff come in when needed to fill in; however, payroll will not show that expectations are met and will show staffing below the minimum required. A review of a facility policy titled staffing hours with revised date of 04/2023, includes: 1. Our facility maintains adequate staffing on each shift to ensure that our residents needs and services are met. 2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outline on the resident's comprehensive care plan. NJAC 8:39-5.1(a), 25.2 (b), 27.1 (a)

Based on interviews and review of other facility documentation, it was determined that the facility allowed Non-Certified Nursing Aides (NAs) to continue working as an NA after the specified 120 days from date of hire. This deficient practice was identified for 7 NAs, (NA1, NA2, NA3, NA4, NA5, NA6, NA7) during the NA review. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health memo dated [DATE], sent to Nursing Homes included the following: Facilities are advised as follows: II. Nurse Aides Nurse Aides (not TNAs) who are enrolled in a NATCEP program must finish training and pass the nurse-aide written or oral exam and the State approved clinical skills competency exam within the usual 120 days, pursuant to N.J.A.C. 8:,d+[DATE].10. After completing the first 16 hours of training, the nurse aide may work in a nursing home while completing the training and testing. After the surveyor review of NA files provided by the facility, on [DATE] at 12:50 PM the surveyor interviewed the Staffing Coordinator and Human Resources Director who both confirmed: NA1 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE]) NA2 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE]) NA3 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE]) NA4 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE]) NA5 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE]) NA6 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE]) NA 7 start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE]) On [DATE] at 10:02 AM, the Director of Nursing said NA's do not have their own assignments. They are buddied with a Certified Nursing Assistant (CNA). They answer lights, pass water and assist the CNA with care. On [DATE] at 02:32 PM the surveyor interviewed the DON who stated that the NAs should not have worked as a NA past 120 days. Review of policy staffing hours revised ,d+[DATE], provided by facility on [DATE] includes: 1. Our facility maintains adequate staffing on each shift to ensure that our residents needs and services are met. 2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outline on the resident's comprehensive care plan. N.J.A.C. 8:,d+[DATE].10

Complaint #NJ169732 Complaint #NJ170765 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a) provide a homelike dining experience on 1 of 2 units, (2nd floor), and b) maintain the facility and equipment in clean and sanitary environment. This deficient practice was identified for 2 of 2 units, (1st and 2nd floor) and was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 a.) During the initial tour of the 2nd floor on 02/27/2024 12:22 PM, Surveyor #1observed the nurse pass the first tray and no placemats observed on the trays. There were no tablecloths on the tables. All food and drinks were left on the tray for all residents and not placed directly on the tables. On 02/28/2024 at 12:05 PM, the 1st meal truck arrived at the dining room/patient lounge on the 2nd floor. Resident meals were observed being served on trays and not placed directly on the tables. During an interview with the surveyor on 03/05/2024 at 10:42 AM, Certified Nursing Assistant (CNA # 4) was asked How are trays served in Dining room/patient lounge for meals? CNA #4 responded the ones (residents) that usually eat in Dining Room, their trays come up first. As soon as tray comes up put on bibs, wash hands and serve the trays. The surveyor asked Is the food served on the tray or removed? CNA responded that staff served the food on the tray. CNA #4 responded, correct when asked if the food was left on the tray. b.1.) During an environmental tour of the 2nd floor on 03/01/2024 at 10:38 AM, the crash cart behind nurses' station was observed to have dust along the black rim on the bottom of the cart. There were dried streaks on red back of cart and black rim at top of cart. The crash cart also had on top of cart is a suction with tubing connected. The end of the tube that would connect to the suction catheter is lying on the base of the machine uncovered and exposed. During an interview with Surveyor #1 on 03/01/2024 at 11:05 AM, Licensed Practical Nurse (LPN #5) was asked who is responsible for checking and maintaining the crash cart. LPN #5 responded if it is used, we would restock. The 11-7 supervisor would restock. During an interview with Surveyor #1 on 03/01/2024 at 11:08 AM, Licensed Practical Nurse/Unit Manager (LPN/UM #1), was asked how is the suction machine to be stored? LPN/UM #1 responded It's always been like that. I can get another one and change it if you want. Surveyor #1 again asked is this the way the tubing and suction machine should be stored, and she replied yes, it's always like that. During an interview with Surveyor #1 on 03/01/2024 at 01:20 PM, the Infection Preventionist (IP) was asked how should a suction machine be stored on the crash cart when not in use? The IP said it should be wrapped in plastic cover. They usually put a trash bag and wrap it. Surveyor #1 asked if it is appropriate to have the tubing attached and lying on the base of the machine? The IP responded No, it should be fresh tubing and should be in the package. During an interview with Surveyor #1 on 03/04/2024 at 02:11 PM, the Director of Nursing (DON) said the suction tubing is tubing connected at time of emergency. The tubing should not be connected and covered when not in use. b.2.) On 02/27/2024 at 12:55 PM, Surveyor #1 observed an unsampled resident sitting in his/her wheelchair. The wheelchair had dried debris on wheels, all support pipes. On 02/28/2024 at 09:23 AM, the unsampled resident's wheelchair still has white stains on cross bars and metal pipes. During an interview with Surveyor #1 on 03/04/2024 at 09:35, the Director of Housekeeping (DHKP) was asked who is responsible to clean the wheelchair and how often are they done. The DHKP replied our nighttime porter is responsible and they are supposed to be cleaned once a week. The DHKP responded yes, we clean outside of medication carts once a week as well. A review of the facility Wheel Chair Cleaning Schedule for January revealed the unsampled resident's wheelchair was documented as having been cleaned on 1/9. A review of the February Wheel Chair Cleaning Schedule revealed the unsampled resident wheelchair was documented as having been cleaned on 2/29. 43936 On 02/27/2024 at 10:25 AM, during the initial tour of the facility, Surveyor # 2 observed a chair in the hallway of the 2C corridor. The chair had a plate left on top of it. The plate had some pasta remaining on it. No residents were in the vicinity at the time of the observation. On the same date at 10:32 AM, during the initial tour of the facility, Surveyor # 2 observed a chair at the end of the hallway in the 2A corridor. The chair had a smeared brown substance on the seat cushion. On the same date at 10:34 AM, during the initial tour of the facility, Surveyor # 2 observed a meal tray on a bedside table in the hallway outside of room [ROOM NUMBER]. The plate on the tray contained remnants of scrambled eggs. No residents were in the vicinity at the time of the observation. 48964 On 02/28/2024 at 12:02 PM, Surveyor #3 met with Resident #171 who stated that he/she noted stains on the privacy curtain and that the housekeeper was told. Resident #171 thinks housekeeper is taking care of it. Surveyor #3 observed the privacy curtain with dark brown stains hanging in his/her room. On 02/29/2024 at 09:58 AM, Surveyor #3 observed the privacy curtain with stains still hanging in Resident #171's room. On 03/04/2024 at 08:45 AM, Surveyor #3 interviewed Resident #171 who stated that the privacy curtain still was not changed and that he/she has asked the housekeeper three more times. Surveyor #3's review of Resident #171's quarterly MDS, an assessment tool, dated 12/31/2023 indicated a Brief Interview of Mental Status (BIMS) of 15, indicating intact cognition. On 03/04/2024 at 09:18 AM, Surveyor #3 interviewed Housekeeper #1 who stated that the porters do the privacy curtains and that she keeps telling them, but they have a million things to do. On 03/04/2024 at 09:32 AM, Surveyor #3 interviewed the DHKP who stated that they try to wash the privacy curtains every month. She also stated that her and the porters check the curtains to determine which ones need changing. She further stated that she has a log of privacy curtains that have been changed. She denied knowing that Resident #171 wanted his/her curtain changed due to stains. Surveyor #3 reviewed the privacy curtain log which revealed that Resident #171's curtain had not been changed. No policy regarding privacy curtains was provided to Surveyor #3. NJAC 8:39-4.1(a)(12), 27.3(c) 31.4(a)(b)

Based on observation, interviews, record review, and review of other facility documentation, it was determined that the facility failed to: 1.) donn (put on) the appropriate personal protective equipment (PPE) prior to entering an isolation room to prevent the transmission of infection 2.) maintain proper infection control practices while performing wound care and 3.) maintain proper infection control practices during the dining observation. This deficient practice was identified for: 1.) 1 of 3 residents (Resident #645) on transmission-based precautions, 2.) 1 of 2 residents observed for wound care (Resident #126), and 3.) 1 of 3 dining rooms observed for meals (first floor dining room). This deficient practice was evidenced by the following: 1. On 02/28/2024 at 12:33 PM, Surveyor #1 observed a Contact Precautions sign at Resident #645's doorway. Instructions on the sign included, but were not limited to: Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. On 03/04/2024 at 08:55 AM, Surveyor #1 observed a Contact Precautions sign at the doorway of Resident #645's room. The surveyor also observed the MDS (Minimum Data Set) (an assessment tool) Coordinator taking food into Resident 645's room without donning the proper PPE (equipment used to minimize exposure to hazards and illnesses) or performing hand hygiene prior to entering or upon exiting the room. The surveyor interviewed the MDS Coordinator as she exited the room and she stated that it was okay because she just put the tray down and came right out. She further stated that there was no need for hand hygiene or PPE. On 02/28/2024 at 01:36 PM, Surveyor #1 reviewed Resident #645's medical record which revealed physician orders for Daptomycin (an antibiotic) to be administered intravenously for twenty-five days for cellulitis (an infection of the skin) and an order for Contact Precautions for MRSA (methicillin resident staphylococcus aureus, a bacterial infection that is resistant to some antibiotics). A review of Resident #645's care plan with a focus area that included suspected/actual infection MRSA in bilateral lower extremities. Interventions included, but were not limited to Contact precautions, apply gown and gloves before every room entry and remove them prior to exit. On 03/04/2024 at 10:00 AM, Surveyor #1 interviewed the Director of Nursing (DON) who stated that for contact isolation all the PPE was needed. She further stated that if staff was observed entering a room on contact isolation without hand hygiene or PPE, the staff member would be wrong. 44833 2. A review of Resident #126's admission record indicated that Resident #126 was admitted to the facility with diagnosis which included, but was not limited to, Parkinson's Disease, bipolar disorder, and morbid obesity. A review of the Resident #126's most recent significant change Minimum Data Set (MDS), a comprehensive assessment tool, dated 1/24/24 indicated Resident #126 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating Resident #126 had severe cognitive impairment, and an unhealed stage three (3) pressure ulcer (bed sore that extends to the fatty layer under the skin) which was being treated with ulcer care, ointments/medications, and had a pressure reducing device for the bed and wheelchair. A review of Residents #126's care plan included, but was not limited to; a care focus area for alteration in skin integrity, resident has an actual stage 3 pressure injury to the left buttock. A review of Resident #126's physician order summary (PO) included an order for calcium alginate (used in the fabrication of wound dressings to assist with wound healing) to be applied to left buttock topically every day shift for wound care, cleanses are with wound cleanser, pat dry with gauze, add calcium alginate, and cover with foam dressing daily. A review of the February 2024 treatment administration record (TAR) indicated the resident's wound care was performed during day shift as ordered. On 02/29/2024 from 2:02 PM to 3:28 PM, Surveyor #2, in the presence of a federal surveyor, observed License Practical Nurse (LPN #2) perform wound care for Resident #126. LPN #2 began the wound care treatment process by bringing the treatment cart containing the needed supplies to the hallway where Resident #126's room was located and placed it along the wall near the resident's room door. At 2:35 PM, while gathering supplies including gauze on a clean barrier pad, LPN #2 stepped away from the treatment cart to the other side of the resident's room door to obtain clean disposable gloves from the box of gloves placed outside the resident's room door. She proceeded back to the treatment cart and placed the clean gloves under her left armpit while opening the new package of clean 4x4 gauze pads. She then donned (put on) the gloves and used them to gather the clean gauze intended to be used for the wound care treatment. At 2:44 PM, LPN #2 entered the resident's room with her treatment supplies, along with a container of disinfectant wipes, marker, and spray bottle of antiseptic spray. She placed these three items on the windowsill as she cleaned and disinfected the tray table to place the clean wound care supplies on. At 3:07 PM, while performing wound care, LPN #2 went to the room doorway and asked a third certified nursing assistant (CNA#3) to put on appropriate personal protective equipment, including but not limited to a disposable gown and gloves, and enter the room to assist with wound care. CNA #3 entered the room having donned clean gloves, with her gloved hands in her pants pockets. She then walked towards the wound care area and as she walked past the tray table with the clean wound care supplies, she grabbed the table along with the clean barrier pad with the wound care supplies on it with both gloved hands that were in her pocket, to move it to a side in order to pass by to where she was needed. At 3:19 PM, once completed with the wound care treatment, LPN #2 gathered the re-usable supplies that she had brought into the room, including a container of disinfectant wipes, a bottle of antiseptic wound spray, and a marker, and without disinfecting any of these items brought them back to the clean treatment cart. She placed the antiseptic spray bottle into the cart drawer and the disinfectant wipes and marker on top of the treatment cart. At 3:28 PM, Surveyor #2 interviewed LPN #2, who confirmed she did not wipe or disinfect these reusable items prior to returning them to the treatment cart, stating I should have wiped them down. Surveyor #2 inquired about placing the clean gloves under her armpit, to which LPN #2 stated, I should not have done that. On 03/01/2024 at 12:59 PM, in the presence of the survey team, Surveyor #2 interviewed the Infection Preventionist Registered Nurse (IP). The IP stated it is not acceptable for staff to hold clean gloves under their armpit prior to use, or to have their clean gloved hands in their pockets prior to contact with resident care supplies. She stated this could cause risk of spreading bacteria or germs to patients. She continued to include that returning re-usable supplies from a resident's room, particularly after wound care treatment, to a treatment cart without disinfecting is also not acceptable, and could spread bacteria or germs. 37547 3. On 02/27/2024 at 9:00 AM, when Surveyor #3 entered the the facility signage was noted on the interior entrance doors that instructed those who entered to Mask Up in Resident Areas, Masks should be worn in all resident areas regardless of vaccination status. The receptionist advised all who entered to donn (put on) a mask that were available at the reception desk and perform hand hygiene prior to check-in at the kiosk, where a touchless thermometer was in use. On 02/27/2024 at 11:59 AM, Surveyor #3 observed dining services in the first floor dining room. Surveyor #3 observed Dietary Aide (DA #3) who failed to donn a mask and wore gloves as she served coffee to the residents. When interviewed, DA #3 stated that she had a mask in her pocket, and had forgotten to put it on prior to meal service. DA #3 declined to answer any further questions. The Regional Clinical Manager (RCM) was present, and stated that masks were not required in the kitchen due to social distancing, but were required in the dining room. The RCM provided DA #3 with a mask to wear at that time. A DA called out to the to the RCM and asked if hand sanitizer was available to hand out to the residents who were already seated and were being served. On 02/27/2024 at 12:14 PM, Surveyor #3 observed Resident #25 and an unsampled resident, who were seated at a table together. They both had already begun to eat their meal when the RCM brought it to a DA's attention that the residents had not received hand wipes. When interviewed, the unsampled resident stated that the facility did not normally provide hand wipes to the residents prior to meal service. The unsampled resident further stated that he/she washed their hands before they went to the dining room. The unsampled resident ambulated with the use of a rolling walker which was observed next to the resident's chair. On 02/27/2024 12:28 PM, Surveyor #3 interviewed the Director of Food Services (DFS) who stated that DA #3 was responsible for meal preparation and did not donn a mask prior to the meal service because she did not normally serve the residents. DFS stated that it was his fault because there was a call out and he was supposed to serve the residents, but was busy speaking with someone in the kitchen. On 02/28/2024 at 12:51 PM, Surveyor #3 interviewed the Infection Preventionist (IP) regarding the facility masking policy. The IP stated that staff were supposed to wear masks in all patient areas. The IP stated the minute the dietary staff stepped out of the kitchen they should have had a mask on in order to keep germs to a minimum. The IP further stated that the facility was remained under outbreak status for Covid-19. At that time, Surveyor #3 asked the IP to describe her expectation for hand hygiene during meal service. The IP stated that residents should have been offered to clean their hands before they received their food. The IP stated if a resident used a rolling walker for ambulation, hand hygiene was essential to keep germs to a minimum. The IP stated that staff were required to perform hand hygiene with hand sanitizer or wipes before they served food and before they fed residents. The IP stated that gloves should not have been worn in the dining room. The IP stated that if gloves were worn, then the staff would have to doff (remove) their gloves and clean their hands, then donn new gloves in between each resident served. On 03/01/2024 at 11:41 AM, Surveyor #3 interviewed the Assistant Director of Nursing (ADON) who stated that all residents should be offered hand hygiene upon entry to the main dining room. The ADON stated that if not offered, the resident's ended up eating with dirty hands. The ADON further stated that it was an infection control issue if hand hygiene were not offered before the meal. At that time, the ADON stated that it was not appropriate for staff to wear the same gloves when they touched different people's plates of food. The ADON stated that everyone should perform hand hygiene between residents. The ADON stated that the facility did not encourage anyone to wear gloves when trays were passed to the residents. On 03/04/2024 at 11:10 AM, Surveyor #3 interviewed the Director of Nursing (DON) who stated that dining room staff were required to wear masks in resident areas in order to protect the residents. The DON stated that gloves should not be worn during meal service for infection control reasons. The DON stated that staff should wash their hands every two to three residents and use hand sanitizer as well. The DON stated that residents should be offered a towelette on entry or at the table as long as it was prior to eating because they could have touched high touch areas and that was an infection control issue. The DON stated that masking had been in place since the first positive case of COVID-19 occurred and remained in place for 14-28 days after. A review of a facility policy titled, Multiple Drug Resistant Organisms (MDROs), with revised date of 12/4/2023, indicated Contact precautions will be implemented for residents with MDROs when secretions, excretions or drainage CANNOT be contained . A review of a facility policy titled, Transmission Based Precautions, with revised date of 5/18/2023, indicated under Contact Precautions: Number two Upon entering the room of a resident in contact precautions, healthcare personnel and visitors should don a gown and gloves. Number three Prior to leaving the room of a resident in contact precautions, healthcare personnel and visitors should doff personal protective equipment and perform hand hygiene. Review of the facility's Wound Care policy with revised date 10/2022, included but was not limited to, wipe reusable supplies with alcohol as indicated (I.e., outsides of containers that were touched by unclean hands, scissor blades, etc.) Return reusable supplies to resident's drawer in treatment cart. Review of the facility's Infection Prevention and Control policy with revised date 4/26/2023 included but was not limited to, this facility follows infection prevention and control policies, procedures, and practices intended to maintain a safe, sanitary, and comfortable environment while helping to prevent the development and transmission of communicable diseases and infections. This facility follows standards of practice in regards to infection prevention and control as outlined and recommended by the Centers for Disease Control and Prevention, Occupational Health and Safety Administration, and/or state specific infection prevention and control guidance. A review of a facility policy titled, Hand Hygiene (Policy No: C-IC-6) (Current Revision Date: 05-18-23) revealed the following: The facility adheres to recommendations by the CDC (Centers for Disease Control) for the practice of hand hygiene in accordance with standard and transmission-based precautions. Hand Hygiene is performed as [sic.] a minimum at these times: .Before and after contact with the resident; .Before meals . Residents are assisted with and/or reminded to perform hand hygiene .before meals, and as needed or requested . NJAC 8:39-19.4(a); 27.1(a)

Complaint # NJ00171057 Repeat deficiency from recertification survey of 09/20/2022 Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently serve foods at a safe and appetizing temperature. This deficient practice was evidenced by the following: On 02/27/2024 at 12:14 PM, during the initial tour of the facility Resident #146 stated that the food has improved but we need more variety, and the portions are small. Resident stated that meal trays arrive between 12:15 and 12:45, you never know. Sometimes food is cold, not what menu says is received. On 2/28/2024 at 10:30 AM, during the resident council meeting 8 of 8 residents attending the resident council meeting complained of cold food to the surveyor. On 02/28/2024 at 09:13 AM, the surveyor observed residents plates on a pellet covered with the bottom of another pellet. On 02/28/2024 at 09:24 AM, Resident #146 had not received his/her breakfast tray. Resident stated that they usually receive breakfast between 9-9:15 AM. Resident stated that they start to get a annoyed when the breakfast comes after 9:30 AM. Meal cart arrived on unit at 9:30 AM and staff started to distribute trays at 9:31 AM. Resident #146 received tray at 9:34 AM. Resident tray was observed to be delivered with only a top plastic pellet cover and no bottom pellet, leaving base of plate exposed on the tray surface and allowing heat to escape. On 02/28/2024 at 12:05 PM the surveyor observed that all meals/trays had no bottom pellets and had bottom pellets covering the food on the plate. The plate was observed to be sitting directly on the meal tray with no bottom pellet in place. The surveyor did not observe any heated element within the pellet. On 02/29/20924 at 10:59 AM the surveyors entered the kitchen, accompanied by the Director of Food Services (DOFS). The surveyors observed that the food for the lunch meal was on the tray line and covered with aluminum foil. The surveyors observed the Cook conduct tray line temperatures at 11:17 AM. The following temperatures were observed: hamburger: 182 F (Fahrenheit) tater tots: 180 F spinach: 179 F mashed potatoes: 179 F mechanical hamburger: 190 F puree hamburger: 185 F pureed spinach: 179 F hot dogs: 184 juice: 40 F Upon completion of the lunch meal temperatures the surveyors exited the kitchen and returned at 02/29/24 at 01:09 PM and observed the lunch tray line actively in progress. The surveyors exited the kitchen at 1:15 PM. The surveyors returned to the kitchen at 1:30 PM to conduct a test tray. The initial food temperatures were conducted at 11:17 AM. The food was present on the tray-line except the hamburgers when the surveyors entered the kitchen. The surveyor observed during the tray-line temperature monitoring that the Food Temperature Log, dated 2/29/24. Menu Week 1 indicated that if the food had been in hot holding for greater than or equal to 2+ hours that food temps should be re-temp. The surveyors entered the kitchen 2 hours post observation of food on the tray-line (11:17 AM). Observation of the Food Temperature Log revealed that no foods had been re-temped after being on the tray-line for 2 plus hours. The surveyor then interviewed the DOFS. On interview the DOFS stated that the food was on the line for greater than 2 hours and that the food temps should have been re-checked. The following time line was conducted to assess food temperatures at the lunch meal: 02/29/2024 01:44 PM test tray asked to be assembled. 02/29/2024 01:47 PM tray placed on 1 D Unit meal delivery cart. 02/29/2024 01:48 PM tray left kitchen with (2) surveyors and the DOFS accompanying the 1 D Unit meal cart. (1 D unit meal cart is the last meal cart to be delivered.) 02/29/2024 01:49 PM cart dropped off on 1 D Unit. 02/29/2024 01:52 PM last tray passed to resident. On 02/29/2024 at 01:54 PM the surveyors observed the DOFS conduct food temperatures on the test tray. The following temperatures were observed: 02/29/2024 01:54 PM Spinach: 130.8 F 02/29/20244 01:54 PM Tater tots: 101.5 F 02/29/2024 01:56 PM Hamburger: 98.4 F 02/29/2024 01:56 PM Coffee:155 F 02/29/2024 01:58 PM Juice: 54.5 F On interview the facility DOFS was asked what the minimum temperatures should be for hot and cold foods. The DOFS responded, We want the food to be delivered at 150-160 F. The surveyors then asked the DOFS why meals were delivered without a bottom pellet. The DOFS responded, A lot of our pellet bottoms are broken so we don't have enough right now for all the plates. I put an order in. The surveyor reviewed the facility policy titled Food Safety-Food Handling Policy, Last Revised Date: 09/2021. The following was revealed under the heading POLICY: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. The following was observed under the heading PROCEDURE: 1. This facility recognizes that the critical factors implicated in foodborne illness are: b. Inadequate cooking and improper holding temperatures; The surveyor reviewed the facility policy titled Food Temperatures Policy, Last Date Reviewed: 3/2023. The following was revealed under the heading POLICY: Food temperatures of food items will be recorded on menu items and substitutions for meal service to maintain a high level of quality assurance and to monitor potentially hazardous food temperatures as per state and federal health regulations thus ensuring that foods are provided in a safe, palatable manner. The following was revealed under the heading PROCEDURE: 2. Meal temperatures will be recorded at the beginning of meal service to ensure proper temperatures are achieved and repeated midway through at point of service if meal service exceeds 2 hours. 6. All employees are responsible to notify their supervisor of any food item that does not meet the regulated safe acceptable service ranges (at or below 41 degrees Fahrenheit or above 135 degrees Fahrenheit). NJAC 8:39-17.4 (a)(2)

Repeat deficiency from recertification survey of 09/20/2022 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide all the items that were on the corporate menu. This deficient practice occurred during one breakfast meal that was observed on the first floor and was evidenced by the following: Repeat deficiency from recertification survey of 09/22/2022 1. On 02/28/2024 at 09:24 AM, Resident #146 had not received their breakfast tray at that time. Resident #146 stated that they usually receive breakfast between 9-9:15 AM. The meal cart arrived on the unit at (9:30 AM and Resident #146 received his/her tray at 9:34 AM.) Resident #146 received scrambled eggs, bagel (whole) with cream cheese, an 8-ounce (oz) skim milk, 6 oz coffee, cold cereal portion control, a small muffin, and 4 oz orange juice. The facility menu provided to the survey team from the Director of Food Services (DOFS) revealed the following meal was to be served at breakfast on 2/28/2024: 4 fl oz (fluid ounce) Cranberry Juice, 6 fl oz Oatmeal, Egg Cheese biscuit 1, wheat toast 1 slice, margarine 1, milk 2% 8 fl oz, coffee 6 fl oz, salt 1 pc (portion control), pepper pc, sugar packet. In addition, the alternate meal was listed as Cream of Wheat 6 fl oz, scrambled egg 1/4 c (cup), white toast 1 slice, and margarine 1. Resident #146 did not choose to receive the alternate meal and should have received an egg cheese biscuit as indicated on the regular menu, dated 2/28/2024 at breakfast. 2. On 02/28/2024 at 10:14 AM, the surveyor conducted an interview with the DOFS. The surveyor asked the DOFS why residents received scrambled eggs and not the menu indicated egg/cheese biscuit the DOFS explained, I'm confused, let me go check something. We don't have an egg and cheese biscuit. The meal ticket indicates that we serve scrambled eggs and toast. The surveyor compared the menu provided to the surveyor by the DOFS and the corporate menu dated Week 1, Wednesday Day 4 for [facility name] F/W 23-24 (fall/winter 2023-2024). Review of both menus indicated that the main meal to be served for breakfast on Wednesday Week 1 was to be the following: Cranberry juice, oatmeal, egg cheese biscuit, 2% milk, and coffee. Review of both menus revealed that the alternate menu to be served was cold cereal, cream of wheat, scrambled eggs, white toast, and margarine. Both menus indicated that an egg and cheese biscuit was to be served as the main menu item at breakfast on Wednesday 2/28/2024 according to the corporate week 1 cycle menu. The surveyor asked the DOFS if they had an egg and cheese biscuit available for breakfast as indicated by the corporate cycle menu. The DOFS stated, No, we don't have an egg and cheese biscuit. The surveyor asked the DOFS if the egg cheese biscuit was prepared in house or was a frozen heat and serve product. The DOFS stated, We make them from scratch, not frozen prepared. The surveyor reviewed the facility policy titled Menu and Preference Policy, last date revised: 3/2023. The following was revealed under the heading POLICY: Menus shall meet the nutritional needs of residents; be prepared in advance; and be followed.' NJAC 8:39-17.2(b)

Based on observation, interview, and review of the medical record, it was determined that the facility failed to ensure a resident was dressed appropriately while in common areas of the unit and did not expose him/herself to other residents as well as failed to transport a resident from one area of the facility to another in a dignified manner. This deficient practice was identified for 1 of 48 sampled residents reviewed for dignity, (Resident # 89) and was evidenced by the following: During the initial tour of the 2nd floor on 02/27/2024 at 10:35 AM, the surveyor observed Resident #89 in Activity room/patient lounge on the 2nd floor in a reclining Geri chair. Resident #89 was dressed in a hospital gown, pulled up and his/her brief exposed to room. 10 other residents were in the room along with activity staff. An unidentified Certified Nursing Assistant (CNA) walked in the room looked at resident and left the room without covering him/her with the blanket. On 02/27/2024 at 12:20 PM, Resident #89 was pushed forward in the Geri chair out of lounge and put in hallway. Gown was observed to have brown colored stains on it. On 03/01/24 10:22 AM, the surveyor observed CNA #1 pulling resident #89 backwards down the hallway in his/her Geri chair. During an interview with the surveyor at that time, CNA #1 said no it is not appropriate to pull a resident backwards in Geri chair. CNA #1 went on to say but the wheels are not moving when do it forward. A review of the Admission Record revealed Resident #89 was admitted with diagnoses including but not limited to; Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) and Muscle Wasting. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 01/19/2024, revealed Resident #89 had impaired short- and long-term memory. The MDS also indicated Resident #89 had severely impaired cognition. Section GG revealed the resident was dependent on staff for bathing, dressing and used a wheelchair for mobility. During an Interview with the surveyor on 02/29/2024 at 11:17 AM, CNA #2 was asked what the process is when you report to work. CNA #2 replied we have permanent assignments. I do assignments or another staff for aides. We get the resident ready for breakfast or if going out on appointment. Then we pass trays and help residents to eat and then do ADL's (Activities of Daily living). When asked how you know what care a resident requires, CNA #2 replied I know every patient and what they like. Their preferences in clothes, food, liquids. I can tell other staff what residents need and will give them report if they are not familiar with any resident. I work both units and have great memory. The surveyor asked what care does Resident #89 require? CNA #2 replied he/she is complete care and is confused. I take him/her to the bathroom, wash him/her up. We keep Resident #89 in eye view at nurses' station and if in bed every 30-minute checks. The surveyor asked if Resident #89 has clothes and CNA #2 replied yes, he/she has clothes. I lay the clothes out when I give him/her care. The surveyor asked how is a resident to be dressed when they are in the patient lounge at activities? CNA #2 said yes, it is a must to be dressed in common areas. CNA #2 confirmed yes, he/she should 100 % wear clothes when out of the room. When questioned what if a resident is dressed in a gown and they pull the gown up and their brief is exposed. CNA #2 replied Aide should pull the gown down and make sure the resident is covered. If not aide or nurse, they should tell the nurse/aide. 100 % all staff should intervene if exposing self or brief. No, not supposed to happen. CNA #2 said I think what happens with this resident is 11-7 has him/her in night gown and may put him/her at nurses' station and then 7-3 leaves him/her. He/she should be dressed as he/she has plenty of clothes. During an interview with the surveyor on 02/29/2024 at 11:36 AM, Licensed Practical Nurse (LPN #1) was asked how should a resident be dressed when they are in common areas or in activities? LPN #1 replied resident should be fully clothed and not in a gown. No one should be in activity with gown on. LPN #1 was questioned What if the gown the resident is in is stained? LPN #1 replied If resident is in gown with stains, someone should take resident and change outfit. During an interview with the surveyor on 03/04/2024 at 10:10 AM, the Director of Nursing (DON) was asked How are residents to be dressed in common areas of the facility? The DON replied some residents refuse to wear clothing, per their preferences. When asked if Resident #89 can make his/her preferences known the DON responded sometimes Resident #89 can make preference known. The DON confirmed No gown should not be stained. The surveyor asked what if resident is in common area and they pull their gown up and their brief is exposed, what should staff that are present do? I would get a sheet and put over him/her and encourage resident to stay covered so as not to expose in any type of way. The surveyor asked What if resident doesn't have clothes? The DON said We have clothes in basement. We have facility center shirts and sweatpants and donated clothes. The surveyor asked What is the appropriate way that a resident in a Geri chair should be transported from location to location in the building? The DON replied we use the big black bar and push them forward. When asked if it is appropriate to pull resident backwards the DON replied No mam' not pulled backwards. NJAC 8:39-4.1(a)

Complaint#: NJ159249 Based on interviews, medical records review, and review of other pertinent facility documentation on [DATE] and [DATE], it was determined that the facility failed to provide the correct Therapeutic Diet to a resident (Resident #2), a cognitively impaired Resident with a known diagnosis of Oropharyngeal Phase Dysphagia (difficulty swallowing), Unspecified Cerebral Infarction and Hemiplegia, and Hemiparesis following Cerebral Infarction, who had a Physician's Order and Plan of Care for a regular diet pureed texture, and Nectar Thick consistency, on [DATE] at approximately 4:30 a.m. According to the Certified Nursing Assistant (CNA #1), Resident #2 asked her for a sandwich, she stated asked the Licensed Practice Nurse (LPN #1) if Resident #2 could have a sandwich, and the LPN said yes. She then gave Resident #2 a whole tuna fish sandwich, which the Resident ate, and she disposed of the rest. According to CNA #2, on [DATE] at approximately 7:15 a.m., she went into Resident #2's room and observed that the head of the bed was completely flat; she thought the Resident was awake, so she talked to him/her, and there was no response, so she touched Resident #2, and the Resident was ice cold. She immediately notified the Charge Nurse Licensed Practice Nurse (LPN #2), a code blue was called at 7:20 a.m., and all staff came to assist. LPN #2 and LPN #3 responded to the code and initiated Cardiopulmonary Resuscitation (CPR). A giant, hard cookie flew off the blanket when Paramedics arrived and pulled the sheets off of Resident #2. According to LPN #2, Resident #2 was lying flat with his/her mouth open with food in the mouth, and she saw a half-eaten sandwich and cookies in the bed with Resident #2. When Resident #2 was turned to put the board under him/her, food was in bed, and the Resident's mouth was open and smelled like peanut butter. Resident #2 death was then pronounced by the Director of Nursing (DON). The facility failed to follow its policies titled Therapeutic Diet Policy, Comprehensive Care Plan, Physician Orders, a company Diet Manual, and the International Dysphagia Diet Standardization Initiative (IDDSI). The facility's failure to provide the correct therapeutic Diet placed Resident #2 and all other residents on a therapeutic diet at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) on [DATE] at 5:35 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on [DATE] and continued through [DATE] when CNA #1 was educated and all staff on the correct snacks to provide residents with a pureed diet. On [DATE], the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating CNA #1 and all facility staff on the diet manual, the diet book, and how to obtain a correct therapeutic diet for residents and the correct snacks to be served to residents on a pureed diet. So the noncompliance remained on [DATE] as a level D for no actual harm with potential for more than minimal harm that is not immediate jeopardy, based on the following: all staff were educated on residents on a therapeutic diet and the correct snacks to be given on a pureed diet. This deficient practice was identified for 1 of 3 residents (Resident #2) and was evidenced by the following: According to the Admission Record (AR), Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Oropharyngeal Phase Dysphagia, Unspecified Cerebral Infarction, and Hemiplegia and Hemiparesis following Cerebral Infarction. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident # 2 had a Brief Interview of Mental Status (BIMS) score of ,d+[DATE], which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #2 needed extensive assistance with most Activities of Daily Living (ADLs) and was total dependence on staff for eating. A review of the Resident's Care Plan (CP) initiated on [DATE] revealed under Focus: Nutrition problem: r/t (related/to) moderate malnutrition, mech (mechanical) altered diet, dysphagia, significant weight loss x 1 mos (month), decreased PO (by mouth) intake. The CP also included under Goal: Resident will be adequately nourished and hydrated via intake from meals and fluids through the review date. Also, under Interventions: included, .Provide regular Diet and puree nectar/mildly thick liquids consistency per MD (Physician) order . A review of Resident #2's Order Summary Report (OSR) dated Active Orders as of [DATE] under Dietary-Diet revealed under Order Summary Regular diet Puree texture, Nectar Thick/Mildly Thick consistency for diet dated [DATE]. A review of Resident #2's Progress Notes (PNs) revealed the following: On [DATE] at 8:26 a.m., the PNs written by the DON revealed Registered Nurse (RN) Assessment called to [the] Resident room. Resident (Resident #2) [was] not breathing and was unresponsive at approximately 0720 (7:20 a.m.). No respirations, apical pulse, or heart/breath sounds [were] auscultated. Code called per full code order. AED (automatic external defibrillator) applied with no shock initiated. CPR (cardiopulmonary resuscitation) immediately initiated and continued until EMTs (Emergency Medical Technicians) arrived. Death [was] pronounced at 0750 (7:50 a.m.). MD (Medical Doctor) and family to be notified. Postmortem care performed. On [DATE], a Narrative PNs written by the Speech Therapist revealed, Resident #2 had signs and symptoms of a swallowing disorder: Holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications .the Resident is on a mechanically altered therapeutic diet to facilitate oral intake .Liquid Consistency/Solids Texture: Nectar Thick/Mildly Thick Puree .Dysphagia Diagnosis . Resident had cognitive impairment with a history of dementia. Patient (Resident) placed on ST (Speech Therapy) program for dysphagia. A review of Resident #2's Speech Therapy SLP (Speech Language Pathologist) Discharge Summary dated [DATE], under Discharge Recommendations (DR), revealed under Strategies: sit upright during and 30 minutes after oral (by mouth) intake, small single bites/sips, alternate bites/sips .Continue puree/nectar thick liquid diet . A review of the facility's Kardex Report (the CNA's plan of care for a resident) as of [DATE] for Resident #2 revealed under the Category of Eating/Nutrition and under Interventions included Provide regular diet and puree nectar/mildly thick liquids consistency per MD (Medical Doctor) order . A review of a Therapy: Swallow, Cognition and Co-morbidities Communication form dated [DATE] for Resident #2 completed by the Speech Therapist under Speech Therapy Summary Sheet revealed the Resident had 1. Signs and symptoms of a swallowing disorder c. Coughing or choking during meals . and 2. Mechanically altered therapeutic Diet to facilitate oral intake a. Yes, ,d+[DATE]. Liquid consistency: Nectar Thick/Mildly Thick, 2.2 Solid Texture g. Puree .5. Supported SLP (Speech Language Pathologist) Comorbidities and Diagnosis: .8. Dysphagia Diagnosis .12. Based on Assessment, does the Resident present with evidence of cognitive impairment (Cognitive assessment/orientation) a. Yes, ,d+[DATE]. Evidence of Cognitive Impairment: history of dementia. 13. Narrative: Completed ST (Speech Therapy) admission screening, Patient (Resident #2) AA&Ox1 (awake, alert & oriented to self). Puree/nectar thick liquid diet (prior level of function). Patient (Resident) not placed on ST program. A review of the facility's Assignment Sheet for [DATE], on the 11:00 p.m. - 7:00 a.m. shift, revealed that LPN #1 and CNA #1 were on the schedule for Resident #2. A review of the Time Cards dated [DATE] to [DATE] and [DATE] to [DATE] for CNA #1 revealed she worked on the following dates: [DATE], [DATE], [DATE], [DATE] and [DATE] on the 11:00 p.m. to 7:00 a.m. shifts. A review of a Teachable Moments (TM) form for LPN #1 revealed, Issue/Reeducation Needed: In-serviced on importance of checking resident diets prior to giving approval for resident meal or snack and where to check. At the bottom of the form, showed Employee signature: printed name of LPN #1 with the Date: [DATE] and Instructor Name/Title: ADON's printed name with the Date: [DATE] and under ADON name was the DON's printed name and date [DATE]. A review of a TM form for CNA #1 revealed Issue/Reeducation Needed: In-serviced on importance of checking resident diets prior to giving approval for resident meal or snack and where to check. At the bottom of the form, indicated Employee signature: printed name of CNA #1 with the Date: [DATE] and Instructor Name/Title: ADON's printed name with the Date: [DATE] and under ADON name was the DON's printed name and date [DATE]. At the time of the survey, the facility could not provide documentation of Resident #2's meal ticket to include his/her meals and snacks for [DATE]. During an interview on [DATE] at 9:36 a.m., the Food Service Director (FSD) stated, each resident's diet is in the meal tracker system, the labeled snacks are individualized to each resident, and sandwiches are made daily. When the surveyor asked him to explain a pureed diet, he replied, a pureed diet is a mousse-like texture of food for people with swallowing problems. He uses a blender to prepare the food. When the surveyor asked him if a sandwich is part of a pureed diet, he replied, No, type of sandwich is considered a puree. Sandwiches are a regular diet. In a second interview at 2:16 p.m., the FSD stated, a peanut butter sandwich is not pureed. It's too hard on the throat and cannot be put into a blender. A peanut butter sandwich is a mechanical Diet. During an interview on [DATE] at 10:30 a.m. with the Speech Therapist in the presence of the Rehabilitation Director (RD), when the surveyor asked her about the pureed Diet, she replied a pureed diet is soft and smooth, and no, sandwiches are not part of a pureed diet. When the surveyor asked about a tuna fish sandwich, she replied, No, on a pureed [diet], cannot be given a tuna fish sandwich with bread. During a telephone interview on [DATE] at 10:21 a.m., LPN #1 stated he worked the night shift, but he knew nothing of Resident #2 or of a resident being unresponsive, and he left by 7:00 a.m. [DATE]. At 10:44 a.m., LPN #1 stated he does rounds every 2 hours this did not happen on my shift. However, he could not recall the unit's nurse or aides' [CNAs] names. During an interview on [DATE] at 12:25 p.m., CNA #2 stated she checks on Resident #2 every morning. On [DATE] at approximately 7:15 a.m., the bed was completely flat when she entered his/her room. She thought the Resident was awake, she talked to the Resident, but when there was no response, she touched him/her. Resident #2 was ice cold, so she immediately ran out of the room and told her Charge Nurse/LPN (LPN #2). A Code Blue was called. According to CNA #2, staff came to assist; CPR was started by LPN #2 and LPN #3, and when the paramedics arrived and flipped the sheet, a big, hard cookie flew off the blanket when they pulled the sheets off of the Resident. She continued to say Resident #2 does not usually lay flat, he/she usually sits upright in bed, and he/she is a pureed [diet]. There was no aide to get a report from when she came on the shift. When the surveyor asked if a cookie was allowed on a pureed diet, CNA #2 replied, No, absolutely not. The Resident should not have a cookie; we would give Resident #2 pudding [for a snack]. CNA #2 stated she was with him/her the night before, and the Resident was perfectly fine. CNA #1 admitted to giving Resident #2 cookies and a sandwich. Resident #2 did not die of natural causes. CNA #2 also stated, I was there during CPR; the DON said to me in the room, what happens in this room stays in this room. She showed the cookie to the DON before she left the floor. At the time of the survey, Resident #2's roommate was not available for an interview. During an interview on [DATE] at 1:09 p.m., LPN #2 stated, I clocked in at 6:30 a.m., and a code blue was called by (CNA #2). When she entered Resident #2's room to start CPR, the Resident was lying flat with his/her mouth open, and I saw food. She further stated when we turned to put the board [CPR board] under [the Resident], she saw food in the bed. [Resident #2's] mouth was open; I could smell peanut butter, and there was a half-eaten peanut butter sandwich and cookies in bed with [him/her]. When the surveyor asked her if she knew Resident #2's Diet, LPN #2 replied he/she is pureed and wouldn't get a sandwich. A pudding would be the Resident's snack. She continued to say nurses would know the Diet because it is charted on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) and if the aide [CNA] doesn't know the Diet to ask us, the nurses. During an interview on [DATE] at 1:30 p.m., when the surveyor asked her about a pureed diet and snacks, the Dietician replied, a pureed Diet is [the] consistency of mashed potatoes, food is made in a blender without lumps. She continued, Pureed snacks are pudding, applesauce, ice cream, and pureed fruit. In the same interview, when the surveyor asked her about a tuna fish sandwich and a peanut butter sandwich, the Dietician replied, tuna fish sandwich is mechanical soft Diet with bread, cut into four pieces, but it is not [a] pureed [Diet]. Puree bread and puree the tuna fish. [A] peanut butter sandwich is a regular texture, and the peanut butter can not be pureed. The Resident could not have a cookie unless pureed and could not have a tuna fish sandwich or a peanut butter sandwich on a pureed diet. We use a company diet manual for diet textures. During a second interview on [DATE] at 1:42 p.m., when the surveyor asked her if a resident on a pureed diet could eat certain foods, the Speech Therapist (ST), in the presence of the RD, stated, No, a resident on a pureed diet cannot eat a peanut butter sandwich or a hard cookie. The DR said, during and after eating, [Resident #2] should be positioned upright for 30 minutes. She explained sitting up after eating, GI (gastrointestinal), and esophageal issues direct food down into the stomach better, a recommendation for dysphasia like him/her. In the same interview, the RD stated Resident #2 was screened [by Speech] and on [the] most appropriate Diet. On [DATE] at 9:39 a.m., the ST in the presence of the RD, stated a pureed diet cannot have sandwiches. During an interview on [DATE] at 2:21 p.m., the DON stated CNA #1 said Resident #2 asked for a snack at 4:00 a.m. she went to the snack cart and allegedly asked LPN #1 if it was OK to give Resident #2 a sandwich. CNA #1 went back into Resident #2's room at 5:00 a.m. and gave Resident #2 a tuna fish sandwich, that's it. Resident #2 was next seen by CNA #2, who found him/her unresponsive. I don't know if anyone [was] in there [room] in between. I didn't see any food in [the Resident's] mouth. When the surveyor asked about the food found with Resident #2, the DON replied, I didn't see a cookie, smell peanut butter or find any food in his/her bed. He/she was on a pureed diet, and I would not give someone [Resident] a sandwich on a pureed diet. When the surveyor asked her the outcome of giving a sandwich on a pureed diet, the DON replied, [resident] could choke. During a telephone interview on [DATE] at 4:43 p.m. with CNA #1, she stated the following happened on [DATE]: I was going to rooms, Resident #2 asked for a snack, there was a sandwich out. Resident #2 wanted a tuna fish sandwich. I went to the nurse, and he checked the diet slip. The nurse said, yes, Resident #2 can have a sandwich. Resident #2 was sitting up at 90 degrees. I gave Resident #2 the sandwich at about 4:30 a.m. The CNA stated she saw Resident #2 again between 5:30- 6:00 a.m. when she did her rounds; the Resident was sitting in bed watching television. During the same telephone interview, the surveyor asked CNA #1 if she knew Resident #2's Diet. She replied, No, I didn't know his/her Diet .so I asked the nurse about the food. That was the only snack I gave him/her; that was it. When the surveyor asked CNA #1 if she was educated on diets, she replied only during her school skills last month; the facility did not provide education. When asked if she was educated or signed any in-services, CNA #1 stated she did not sign anything [paperwork on diet education] and was only suspended for three days after this incident. She returned to work on [DATE]. During an interview on [DATE] at 10:20 a.m., CNA #3 stated CNA #1 said she gave Resident #2 and his/her roommate both snacks that morning. She gave Resident #2 a cookie and a sandwich but did not say what kind of sandwich. During a telephone interview on [DATE] at 2:22 p.m., the Nurse Practitioner (NP) stated she was just told; Resident #2 had passed away. At the time, the staff did not say anything about the incident surrounding the call. I found out a few days after what happened from the nurses. She continued, Nurses think that (Resident #2) got the wrong Diet and may have choked. A review of the facility policy titled Therapeutic Diet Policy with a last date revised ,d+[DATE] revealed the following: Under Policy: included therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Under Procedure: .4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner, or Dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the Diet, or to alter the texture of a diet, for example, a. Consistent Carbohydrate; LCS .9. Snacks will be compatible with the therapeutic Diet . A review of the facility policy titled Care Plans-Comprehensive with a last date revised ,d+[DATE] revealed the following: Under Policy: included A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Procedure: .4. Each resident's care plan will be consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to: .g. Receive the services and/or items included in the plan of care; .13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change . A review of a facility policy titled Physician Orders with a creation date ,d+[DATE] revealed the following: Under Policy: included It is the policy of this facility to secure physician orders for care and services for residents as required by state and federal law. Physician orders will be dated and signed according to state and federal guidelines. A review of a facility Diet Manual dated 2021 revealed the following: Under Pureed Diet included Description and Indication The Pureed Diet is designed using the Regular Diet and the mechanically altering the texture of the food items into a pureed consistency. This Diet is indicated for residents with difficulty swallowing and/or residents who are unable to tolerate Ground Soft Diet/Minced and Moist. The goal is to improve or maintain the Resident's nutritional status and provide foods that are safe to swallow, minimizing the chance for aspiration problems. Under Nutritional Adequacy included The Pureed Diet is nutritionally equivalent to the Regular Diet unless any other therapeutic restrictions are specified . Under Preparation of Foods in a Pureed Diet Menu included Food items must be prepared by using a food processor or blender unless food item is already in a pureed form like: mashed potatoes, custard and strained cream soups. Foods are thickened if necessary to achieve a custard or mashed potato consistency using commercial food thickeners or food items like mashed potato flakes. At times it may be necessary to add liquid instead of thickening the food. Liquids used include: gravies, broth, juices or milk. Water is not used since it caused flavor loss then, resulting in poor intake. Product should NOT have any pieces in it and should not thin puree. A review of the International Dysphagia Diet Standardization Initiative (IDDSI) titled IDDSI Special Feature dated Sept (September) 2020 Focus on Puree revealed the following: Under Why are pureed foods recommended? included .A puree should have a smooth consistency with very fine particles so that chewing is not required. The pureed food is held together with just enough structure and is slippery enough so that it can be moved from the front of the mouth to the back and swallowed with minimal effort. These factors promote a safe way to consume food when oral coordination or strength is impaired . N.J.A.C.: 8XXX,d+[DATE].4 (a)(2)

Complaint#: NJ159249 Based on interviews, medical records review, and review of other pertinent facility documentation on 11/3/2022 and 11/7/2022, it was determined that the facility failed to implement a comprehensive care plan (CP) for a resident on a regular diet pureed texture, Nectar Thick, Mildly Thick Consistency for 1 of 3 residents (Resident #2). The facility also failed to follow its policy titled Comprehensive Care Plan .This deficient practice was evident in 1 of 3 care plans, as evidenced by the following: According to the Admission Record (AR), Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Oropharyngeal Phase Dysphagia, Unspecified Cerebral Infarction, and Hemiplegia and Hemiparesis following Cerebral Infarction. According to the Minimum Data Set (MDS), an assessment tool dated 10/01/2022, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 3/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #2 needed extensive assistance with most Activities of Daily Living (ADLs) and was totally dependent on staff for eating. A review of the Resident's Care Plan (CP) initiated on 06/24/2021 revealed under Focus: Nutrition problem: r/t (related/to) moderate malnutrition, mech (mechanical) altered diet, dysphagia, significant weight loss x 1 mos (month), decreased PO (by mouth) intake. The CP also included under Goal: Resident will be adequately nourished and hydrated via intake from meals and fluids through the review date. Also, under Interventions: included, .Provide regular diet and puree nectar/mildly thick liquids consistency per MD (Physician) order . During an interview on 11/7/2022 at 11:00 a.m., the Assistant Director of Nursing (ADON) stated, the purpose of the CP is to know how to care for residents, meet their needs, set goals and interventions. When the surveyor asked him if the CP was followed for the Resident, he replied, Resident #2's care plan was not followed according to his/her diet since he/she received a sandwich and his/her family and the doctor (Physician) should have been notified of the wrong diet given. During an interview on 11/7/2022 at 1:04 p.m., the DON stated, the purpose of the CP is to know what to do with the Resident and to keep them safe. The CP for Resident #2 was not followed because they gave him/her a sandwich A review of the facility policy titled Care Plans-Comprehensive with a last date revised 10/2019 revealed the following: Under Policy: included A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Procedure: .4. Each resident's care plan will be consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to: .g. Receive the services and/or items included in the plan of care; .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . N.J.A.C.: 8.39-27.1 (a)

C#: NJ 9, NJ 4, NJ 9, NJ 0 Based on interviews, review of the medical records, and review of other pertinent facility documents, on 2/15/2022, 2/16/2022, and 2/19/2022, it was determined that the facility failed to consistently follow residents' care plans, evaluate residents for pain and ensure that pain medications were administered according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to follow its policies titled Pain Management and Medication Administration-Documentation. This deficient practice occurred on 2/12/2022 and 2/13/2022 on the 11:00 p.m. to 7:00 a.m. shift, on 5 of 8 units and for 5 of 7 residents (Resident #1, #2, #3, #4 and #5) reviewed, and was evidenced by the following: A review of a facility's policy dated 7/2019 and titled; Pain Management included the following: Under Purpose: The facility is committed to reducing physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning. The facility recognizes that a resident's response to pain is subjective and individual .The facility promotes resident self-reporting as the most reliable indicator of pain. Facility clinicians use objective pain scales when caring for residents that are able to assist in determining the severity of pain and effectiveness on interventions. Under Policy revealed .3. Include the resident .in the following: Evaluation of pain .Determine resident's pain goal and acceptable level of pain. 4. Identify the potential cause(s) for resident pain. Evaluate alleviating and/or exacerbating factors. Review effectiveness of past and current treatment, as well as specific spiritual and cultural issues related to pain. A review of a facility's policy dated 1-2019 and titled Medication Administration-Documentation revealed the following: Under Policy included: The facility shall maintain a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation must include, as a minimum: .e. Reason (s) why a medication was .not administered During a tour on 2/15/2022, the surveyors interviewed Resident #2 at 11:45 a.m. Resident #2 told the surveyors that on Saturday night (2/12/2022) during the 11:00 p.m. to 7:00 a.m. shift, the resident was supposed to receive his/her routine pain pill at 12:00 a.m. but never received it. Resident #2 stated he used the call bell to call for his medication and was told by the Certified Nursing Assistant (CNA #1) that the resident did not have a nurse. Resident #2 stated he/she was in pain but did not have a nurse that night, so he/she could not get the pain medication administered and had to call 911. When asked by the Surveyor the pain level on a 0 to 10 scale, with 10 being the most severe, Resident #2 stated that his/her pain was a 10. Resident #2 explained to the surveyors that since he/she did not receive the pain pill, the resident started to feel sick, nausea and vomiting and said to CNA #1, please, can I get my pain pill. However, the resident still didn't get it, so this was when Resident #2 called 911, and the paramedics and police came. Resident #2 further explained to the surveyors that his/her next dose of pain medication was scheduled for six hours later at 6:00 a.m. The resident also did not receive the 6:00 a.m. pain medication and the early morning medications due on the 11:00 p.m. to 7:00 a.m. shift. Resident #2 stated that he/she received the pain pill and the other medications due on the following shift at 7:45 a.m. Review of the facility's daily census report dated 2/12/2022 showed the facility had 105 residents on the first floor as follows: 24 residents on unit 1A, 23 residents on unit 1B, 28 residents on unit 1C, and 30 residents on unit 1D. A review of the facility's staff assignment sheets dated 2/12/2022 revealed that the facility had only one nurse (Licensed Practical Nurse) LPN #1 assigned to the 1A and 1B units. No nurse was assigned to care for the 58 residents on the 1C and 1D units. Further review of the facility's daily census report dated 2/12/2022 showed the facility had a total of 110 residents on the second floor as follows: 29 residents on unit 2A, 28 residents on unit 2B, 23 residents on unit 2C, and 30 residents on unit 2D. A review of the facility's staff assignment sheets dated 2/12/2022 revealed the facility had only one nurse, LPN #2, assigned to the 2C and 2D units. No nurse was assigned to care for the 57 residents on the 2A and 2B units. Review of the facility's daily census report dated 2/13/2022 showed the facility had 103 residents on the first floor as follows: 22 residents on unit 1A, 23 residents on unit 1B, 28 residents on unit 1C, and 30 residents on unit 1D. A review of the facility's staff assignment sheets dated 2/13/2022 revealed the facility had only one nurse (LPN #1) on the floor and assigned the LPN to the 1C and 1D units. No nurse was assigned to care for the 42 residents on the 1A and 1B units. Review of the Electronic Medical Records (EMRs) were as follows: 1. According to the Admission Record (AR), Resident #2 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool dated 2/2/2022, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. The MDS also showed the resident needed extensive assistance with most Activities of Daily Living (ADLs) and received a scheduled pain medication regimen. Further review of the MDS also showed that a pain assessment should be completed for the presence of pain, and the resident has pain frequently with a pain intensity rating of 7 out of 10, with 1 being the lowest and 10 being the highest pain. A review of Resident #2's CP revealed the following: Under Focus: Resident is on pain management therapy due to an alteration in comfort R/T Chronic pain and [CONDITION(S)], undated. Under Goals: Resident's pain goal is to be free from pain during movement .able to verbalize pain and request pain medications as needed .will achieve pain goal to be free of pain while at rest through the review date (undated), under Interventions: Administer medications as ordered, Evaluate the effectiveness of pain interventions as needed. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia, including pain relief, side effects, and impact on function. Identify, record, and treat the resident's existing conditions which may increase pain and or discomfort, Monitor for S/S of pain with each interaction. If the resident appears to be in pain, utilize appropriate non-pharmacological and pharmacological interventions. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/document for side effects of pain medication. Observe for constipation, new-onset or increased agitation, restlessness, confusion, hallucinations, nausea, vomiting, dizziness, and falls. Report occurrences to the physician, Notify physician if interventions are unsuccessful or if the current complaint is a significant change from residents the past experience of pain, PMR consult, PMR Referral, Provide distraction/activities as needed, Report to Nurse resident complaints of pain or requests for pain treatment, undated. Review of the Order Summary Report (OSR) for Resident #2 dated 2/15/2022 included the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Pain Evaluation Q (every) shift for pain evaluation, record pain on a 0-10 scale, dated 10/13/2019. [MEDICATION(S)] HCI ([MEDICATION(S)]) Tablet 30 mg (milligram). Give 1 tablet by mouth every 6 hours for moderate pain, dated 10/13/2019. A review of the 02/01/2022-02/28/2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Pain Evaluation Q shift for pain evaluation on 2/12/2022 on the 11:00 p.m. to 7:00 p.m. shift. was blank. [MEDICATION(S)] HCI Tablet 30 mg. Give 1 tablet by mouth every 6 hours for moderate pain, on 2/13/2022 at 12:00 a.m. was blank. During an interview on 2/15/2022 at 2:59 p.m., CNA #1 stated that Resident #2 rang the call light and told him he/she needed his medications. CNA #1 said the nurse (LPN #2) knew Resident #2 needed his/her medication because he reported it to her. When asked by the Surveyor what the nurse did or said when he told her Resident #2 needed his/ her medications, CNA #1 stated she did not say anything when he told her Resident #2 needed his/her meds. CNA #1 stated Resident #2 was crying and called 911. 2. According to the AR, Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, dated [DATE], Resident #3 had a BIMS score of 15/15, indicating the resident was cognitively intact. The MDS also revealed Resident #3 needed extensive assistance with most ADLs, and the resident received pain medication as needed (PRN). Further review of the MDS also showed that a pain assessment should be completed for the presence of pain, and the resident has frequent pain, making it hard to sleep at night and has limited day-to-day activities because of the pain. A review of Resident #3's CP revealed the following: Under Focus: Alteration in comfort R/T (actual) chronic pain, undated. Under Goals: Resident is able to verbalize pain and request pain medications as needed, and the resident will achieve pain goal of tolerable pain while at rest through the review date, undated, under Interventions: Administer medications as ordered, Monitor for S/S of pain with each interaction. If the resident appears to be in pain, utilize appropriate non-pharmacological and pharmacological interventions. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/document for side effects of pain medication. Observe for constipation, new-onset or increased agitation, restlessness, confusion, hallucinations, nausea, vomiting, dizziness, and falls. Report occurrences to the physician, Notify physician if interventions are unsuccessful or if the current complaint is a significant change from residents the past experience of pain, Report to Nurse resident complaints of pain or requests for pain treatment, Utilize non-pharmacological pain interventions to promote comfort, Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing), pain, undated. Review of the OSR for Resident #3 dated 2/15/2022 included the PO's for the following: Pain Evaluation Q (every) shift for pain evaluation, record pain on a 0-10 scale, dated 11/30/2021. [MEDICATION(S)] HCI ([MEDICATION(S)]) Tablet 10 mg. Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. 6-10, dated 11/30/2021. A review of the 02/01/2022-02/28/2022 MAR for Resident #3 confirmed the staff failed to perform a pain assessement and the aforementioned PO's were not administered on 2/12/2022 and 2/13/2022 on the 11:00 p.m. to 7:00 a.m. shift as follows: [MEDICATION(S)] HCI ([MEDICATION(S)]) Tablet 10 mg. Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. 6-10, on 2/13/2022 on the 11:00 p.m. to 7:00 a.m. shift. Pain Evaluation Q shift every shift for pain evaluation record pain on a 0-10 scale on 2/13/2022 on the 11:00 p.m. to 7:00 a.m. shift. A review of the Progress Notes (PNs) dated 2/14/2022 at 3:57 a.m., written by Licensed Practical Nurse (LPN #4), revealed that Resident #3 contacted emergency services due to pain. Resident requested to be taken to (Hospital) During an interview on 2/19/2022 at 7:15 a.m., Resident #3 stated that the nurses on the unit were not showing up repeatedly on the night (11:00 p.m. to 7:00 a.m.) shift. The resident explained he/she did not receive his/her medication for the entire night shift when the resident called 911. Resident #3 explained to the Surveyor that the resident was in severe pain to his/her hands, prostate, back, joints and knees. Resident #3 used the call button, the staff responded, and the resident told them that he/she was in pain and needed his/her pain pill. The resident stated he/she repeatedly asked for the pain medication, but the nurse would not give the medication to him/her. The resident said he/she had no choice but to call 911 in the morning hours to take him/her to the Hospital. Resident #3 continued to explain, When I am in really bad pain, my blood pressure goes up, and I get sick. I told the nurse I had diarrhea and vomiting, and they did nothing. The resident stated he/she received the needed medication ([MEDICATION(S)]) at the Hospital by mouth and the symptoms were relieved slowly. When asked by the Surveyor what was the resident's pain level on a 0-10 scale, Resident #3 stated his/her pain was over 10. 3. According to the AR, Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, dated [DATE], Resident #1 had a BIMS score of 15/15, indicating the resident was cognitively intact. The MDS also showed that the resident needed ADL assistance and received a scheduled pain medication regimen and PRN. The MDS also showed that pain assessment should be completed for the presence of pain, listed his pain as occasionally and at level 5 out of 10, with 1 being the lowest and 10 being the highest pain. A review of Resident #1's Care Plan (CP) revealed the following: Under Focus: Resident has alteration in comfort R/T (related to) post-op (operation) discomfort, muscle spasms, [CONDITION(S)], dated 7/30/2021. Under Goals: Resident pain will improve as part of the healing process .will achieve pain goal of tolerable pain while at rest through the review date, dated 7/30/2021, under Interventions: Administer medications as ordered, Evaluate the effectiveness of pain interventions as needed. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, Identify, record and treat the resident's existing conditions which may increase pain and/or discomfort, Monitor for S/S (Signs and Symptoms) of pain with each interaction. If resident appears to be in pain, utilize appropriate non-pharmacological and pharmacological interventions; monitor/document for side effects of pain medication. Observe for constipation, new-onset or increased agitation, restlessness, confusion, hallucinations, nausea, vomiting, dizziness, and falls. Report occurrences to the physician, Report to Nurse resident complains of pain or requests for pain treatment, Reposition frequently ., dated 7/30/2021. Review of the OSR for Resident #1 dated 2/15/2022 included the PO's for the following: Pain Evaluation Q (every) shift for pain evaluation, record pain on a 0-10 scale, dated 07/29/2021. [MEDICATION(S)] HCI ([MEDICATION(S)]) Tablet 15 mg. Give 1 tablet by mouth two times a day for pain management, dated 12/15/2021. [MEDICATION(S)] Tablet 800 mg. Give 1 tablet by mouth every 8 hours for [CONDITION(S)], dated 09/02/2021. A review of the 02/01/2022-02/28/2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Pain evaluation Q shift every shift for pain evaluation. Record pain on a 0-10 scale on 2/12/2022 on 11:00 p.m. to 7:00 a.m. shift. was blank. [MEDICATION(S)] HCI ([MEDICATION(S)]) Tablet 15 mg. Give 1 tablet by mouth two times a day for pain management, on 2/13/2022 at 4:00 a.m. was blnak. [MEDICATION(S)] Tablet 800 mg. Give 1 tablet by mouth every 8 hours for [CONDITION(S)], on 2/13/2022 at 6:00 a.m. was blank. During an interview on 2/15/2022 at 3:25 p.m., Resident #1 stated that on the 11:00 p.m. to 7:00 a.m. shift, he/she missed his/her pills on Saturday into Sunday because there was no nurse on the C unit. The resident stated he/she had to wait until the 7:00 a.m. nurse came on duty to give the medications, and his/her pain level was a 7/10. 4. According to the AR, Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, dated [DATE], Resident #4 had a BIMS score of 14/15, indicating the resident was cognitively intact. The MDS also showed the resident needed extensive assistance with most ADLs; the resident received a scheduled pain medication regimen and additionally received pain medication PRN. Further review of the MDS also showed that a pain assessment should be completed for the presence of pain, and the resident had pain frequently with a pain intensity rating of 7 out of 10, 0 being the lowest and 10 being the highest pain. Review of Resident #4's CP revealed the following: Under Focus: Resident may have Alteration in comfort R/T Immobility, Wound, dated 7/28/2021. Under Goals: Residents pain goal is to have a tolerable level from pain during movement through the review date, dated 7/28/2021, under Interventions: Monitor for S/S of pain with each interaction If resident appears to be in pain, utilize appropriate non-pharmacological and pharmacological interventions and pain, dated 7/28/2021. Review of the OSR for Resident #4 dated 2/15/2022 included the PO's for the following: Pain Evaluation Q shift for pain evaluation, record pain on a 0-10 scale, dated 7/28/2021. [MEDICATION(S)] HCI Tablet 10 mg. Give 1 tablet by mouth every 8 hours for pain management, dated 2/7/2022. A review of the 02/01/2022-02/28/2022 MAR for Resident #4 confirmed the staff failed to perform a pain assessment and the aforementioned PO's were not administered on 2/12/2022 on the 11:00 p.m. to 7:00 a.m. shift (2/12/2022 into 2/13/2022) as follows: [MEDICATION(S)] HCI Tablet 10 mg. Give 1 tablet by mouth every 8 hours for pain management on 2/13/2022 at 6:00 a.m. was blank. Pain Evaluation Q Shift every shift for pain evaluation record pain on a 0-10 scale on 2/13/2022 on 11:00 p.m. to 7:00 a.m. shift. was blank. 5. According to the AR, Resident #5 was readmitted to the facility on [DATE] and originally admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, dated [DATE], Resident #5 had a BIMS score of 7/15, indicating the resident had moderately impaired cognition. The MDS also showed the resident needed assistance with most ADLs; the resident received a scheduled pain medication regimen and additionally received pain medication PRN. Further review of the MDS also showed that a pain assessment should be completed for the presence of pain, and the resident has pain almost constantly, and the pain is severe. A review of Resident #5's CP revealed the following: Under Focus: Alteration in comfort R/T S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Under Goals: Resident pain will improve as part of the healing process, and resident is able to verbalize pain and request pain medications as needed through the review date, undated, under Interventions: .Administer medications as ordered .Evaluate the effectiveness of pain interventions as needed. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition .remind of non-pharmacological interventions, i.e. (for example): relaxation sound machine, aroma diffuser available on request to recreation, Report to Nurse resident complaints of pain or requests for pain treatment, resident is able to verbalize pain and request pain medications as needed, undated. Review of the OSR for Resident #5 dated 2/15/2022 included the PO's for the following: Pain Evaluation Q (every) shift for pain evaluation, record pain on a 0-10 scale, dated 5/24/2018. Monitor resident behaviors (sadness, anxiety, refusal to sleep in the bed) every shift and record the number of episodes, dated 11/3/2020. [MEDICATION(S)] Capsule 100 mg. Give 1 capsule by mouth every 8 hours for nerve pain, dated 09/17/2021. A review of the 02/01/2022-02/28/2022 MAR for Resident #5 confirmed the staff failed to perform an assessment for behavior and pain. Also, the aforementioned PO's were not administered on 2/12/2022 and 2/13/2022 on the 11:00 p.m. to 7:00 a.m. shift (2/12/2022 into 2/13/2022 and 2/13/2022 into 2/14/2022) as follows: Monitor resident behaviors (sadness, anxiety, refusal to sleep in the bed) every shift and record the number of episodes on 2/13/2022 at 11:00 p.m. to 7:00 a.m. shift. was blank. [MEDICATION(S)] Capsule 100 mg. Give 1 capsule by mouth every 8 hours for nerve pain on 2/13/2022 & 2/14/2022 at 6:00 a.m. were blank. Pain Evaluation Q (every) shift for pain evaluation, record pain on a 0-10 scale on 2/13/2022 from 11:00 p.m. to 7:00 a.m. was blank. Review of Resident #1's, #2's, #3's, #4's, and #5's EMR showed no documented evidence that the residents' CP was followed had a pain evaluation completed or received their pain medications according to the PO's order. During an interview on 2/16/2022 at 9:26 a.m., the Staffing Coordinator confirmed she received a text on 2/11/2022 on the 11:00 p.m. to 7:00 a.m. shift, at 12:00 a.m. but did not see the text until she woke up. According to the Staffing Coordinator, the text was also sent to the DON and the HR Director. Since there was no response from the group, she assumed it was resolved. The Staffing Coordinator further stated she was aware that nursing was short-staffed, but the HR Director also handles the weekend schedule. During a telephone interview on 2/16/2022 at 11:11 a.m., LPN #1 indicated that on 2/12/2022, on the 11:00 p.m.to 7:00 a.m. shift, she was the only nurse on the first floor and was assigned to units 1A and 1B. LPN #1 also stated that LPN #2 was the only nurse assigned to the second floor on the 11:00 p.m. to 7:00 a.m. shift on 2/12/2022. The LPN explained that on 2/12/2022, on the 11:00 p.m.to 7:00 a.m. shift, she was the only nurse on the first floor for units 1A 1B, 1C, and 1D, with the resident census of 105. LPN #1 further explained that she could not care for all of the first-floor residents and only provided care for some residents. She stated some residents were crying, complaining they were not getting their medications, and came up to the nurses' station, and she administered those residents their medications. LPN #1 also stated that a resident called the police from the second floor. LPN #1 further stated that the next night on 2/13/2022, on the 11:00 p.m.to 7:00 a.m. shift, she was again the only nurse on the first floor (units 1A, 1B, 1C, and 1D) with the resident census of 103. She further stated that a resident called 911 and went to the Hospital because he/she did not receive pain medications as no nurse was on his/her cart. The LPN explained, on 2/13/2022, during the 11:00 p.m. to 7:00 a.m. shift, she sent out a mass text message to the Director of Nursing (DON), the Human Resources (HR) Director, and other facility staff that they were only two nurses on duty in the entire building, for a census of over two hundred residents. According to LPN #1, Resident #3 called down to the first floor from the second floor to get his/her medication. She told the resident that she would notify the nurse on the second floor. LPN #1 explained she called LPN #4, who did not give the resident the pain medication, so the resident called 911. LPN #1 also stated Resident #3 was vomiting. During a telephone interview on 2/16/2022 at 1:00 p.m., when asked by the surveyor if she received a text from LPN #1 about being the only nurse on the floor on 2/11/2022 on the 11:00 p.m. to 7:00 a.m. shift, the HR Director confirmed that she received a group text from the nurse during the night between 12:30 a.m. to 2:30 a.m. According to the HR Director, she replied to the nurse's text message but did not follow up with anyone else. She explained that the nurse should have contacted the on-call Supervisor. The HR Director explained that she does not take calls off shift and the Supervisor handles that on-off shifts. She was unsure who was the on-call Supervisor. During a telephone interview on 2/16/2022 at 1:13 p.m., LPN #4 confirmed she was assigned to the second floor on the 2C and 2D units on Sunday (2/13/2022) on the 11:00 p.m. to 7:00 a.m. shift. The LPN stated there was no other nurse on the floor, and she told the HR Director. LPN #4 explained that Resident #3 requested his/her pain medication at 3:00 a.m., but she did not want to take the keys because she did not count the cart with anyone. The LPN continued to explain the facility is short-staffed every night. During an interview on 2/16/2022 at 3:33 p.m., the Director of Nursing (DON) stated the Supervisor was on vacation, and a Supervisor did not work on 2/12/2022 and 2/13/2022. The DON also confirmed that she received the text message sent out on 2/13/2022 during the 11:00 p.m. to 7:00 a.m. shift by LPN #1. The DON explained that the text message was at 2:07 a.m., and she did not hear the text message alert. When asked by the Surveyor why she did not get more nurses or why she did not come into assist the 11:00 p.m. to 7:00 a.m. shift, the DON responded that LPN #1 should have called instead of texting; she did not see the text message until the morning. The shift was almost over, so she did not go to the facility to help. The DON further explained that the staffing schedules are looked at before the weekend begins. She explained that the Staffing Coordinator should have been aware that the nursing staff was short because there was only one nurse on the schedule for 2/12/2022 on the 11:00 p.m. to 7:00 a.m. shift on units 1A 1B, 1C, and 1D. The DON also stated pain medications should be given when requested, and if a resident did not receive pain medication, the nurse would be written up; I did not write up the nurses from this past weekend yet. During a second interview on 2/19/2022 at 10:35 a.m., when the surveyor asked what blank spaces mean on the MAR, she stated blank spaces mean the medication was not administered or not documented. The DON further stated she was not aware of the residents' medications being missed and the police being called until after the fact, the following day (2/13/2022) after the shift was over. N.J.A.C.: 8:39-27.1(a)

C# NJ Based on interviews and review of medical records and other facility documentation, it was determined that the facility failed to consistently implement interventions to prevent skin impairment and promote healing for 1 of 4 sampled residents (Resident #3) reviewed. In addition assessments did not accurately indicate which heel had an unstageable pressure ulcer. On admission, Resident #3 had no skin impairment and developed an unstageable pressure ulcer on the right heel 24 days after entering the facility. This deficient practice is evidenced by the following:1. According to the physician's orders [REDACTED].A Minimum Data Set (MDS), an assessment tool, dated 9/9/12, reflected that the resident was cognitively intact, at risk for pressure ulcers, but had none. She required extensive assistance with Activities of Daily Living (ADL) such as dressing, hygiene and bathing.The Braden Scale, dated 9/2/12, showed a score of 13. A score more than 12 represented low risk for developing a pressure ulcer.The Admission Assessment, dated 9/2/12, documented the resident was oriented to person only, sometimes understands, had bruising but not on the feet and no open areas. The instructions for the skin condition assessment indicated that all body marks, including pressure ulcers and soft heels would be documented. The Interdisciplinary Progress Notes by the Licensed Practical Nurse (LPN), dated 9/2/12 at 6:50pm documented the resident's skin was warm, dry and intact. The physician's Admission History and Physical, dated 9/7/12, reflected the resident had multiple bruises and intact skin. The Nutrition Assessment, dated 9/6/12, revealed the resident was alert and oriented with some confusion and lab tests done on 9/4/12 for [MEDICATION NAME] showed moderate protein depletion and prosource, a supplement, was recommended.The POF dated 9/2/12 indicated weekly skin checks. On 9/6/12 prosource was ordered twice a day.A review of the resident's Interdisciplinary Care Plan (CP) created on 9/2/12, documented an alteration in ADLs and an intervention was to check skin every shift. That day, another CP for potential skin impairment was also initiated due to DM, impaired mobility, fragile skin and incontinence. Interventions included to assess skin condition daily during care, keep skin dry, clean and well lubricated and use caution when giving care.On 9/26/12 a CP for actual skin impairment was initiated which indicated two pressure ulcers. The left heel was unstageable and the right heel had a stage I pressure ulcer. Although there was a checklist of options for interventions, none were checked.The undated Interdisciplinary Care Plan reflected the resident was disoriented to time and place and "pressure/stg (stage) I (R) (right) heel skin prep daily to (R) & (L) (left) heel." The section titled "Preventive devices" included options for special mattress, foot cradle, positioning, heel pads and other, but none of these preventive devices were checked. The surveyor interviewed the LPN/Unit Manager (UM)#2 on 10/16/12 at 2:30pm and asked if there was a Certified Nursing Assistants (CNA) care plan/card with interventions/type of care the resident required. She stated the CNA's should review the Interdisciplinary Care Plan for resident care needs and interventions. A review of physician order [REDACTED]. A review of the October 2012 POF revealed no skin prep order. The Routine Treatment sheet, for September and October 2012 reflected that skin prep treatments were signed as done on all days. During a care tour on 10/16/12 at 9:15am with the LPN/Unit Manager #1 of Resident #3's unit, the resident was in bed and the CNA was just beginning to provide AM care. The resident was on a pressure relieving mattress which UM #1 stated all residents receive on admission. The resident was wearing socks and when removed the right heel was observed to have a blackened area (unstageable). At 11:40am, the resident was observed wearing shoes and sitting in her room in a wheelchair with her legs slightly elevated. Daily Skilled Nursing Documentation for 9/26/12 by the 7am-3pm shift LPN indicated a 1 centimeter (cm) by 2.3 cm stage I "dark pigmented pressure wound" and an order for [REDACTED].A Wound/Skin Healing record, dated 9/26/12, indicated the resident's right heel had a 1cm by 2.3cm stage I pressure ulcer. The left heel had a 3cm by 3cm unstageable pressure ulcer. Assessment documentation dated 9/26, 10/3 and 10/10/12 were the same with no changes noted.In a post survey telephone interview with the Director of Nursing (DON) on 10/17/12 at 3:55pm, she verified that it was the resident's right heel that had the unstageable pressure ulcer and not the left heel as indicated on the wound/skin healing record.During interviews on 10/16/12 at 11:15am and 2:45pm, LPN/Unit Manager #1 stated that skin checks are done weekly on 1 of the 2 shower days. If there is skin breakdown, the doctor and wound consultant are notified. Every Tuesday the wound nurse assesses the wound and every Wednesday the Unit Manager does an assessment of the wound. There would be a podiatry consult and staff would offload (reduce the pressure to an affected area) by placing a pillow under the resident's calf and a skin prep would be done. She also stated you "need an order for [REDACTED].#1) stated she did not give report today (10/16/12). An interview with the CNA assigned to the resident on the day of survey (10/16/12) at 3pm revealed that this was the first time she provided care for the Resident #3 and usually she gets a report from the nurse, but didn't today and asked the resident's usual CNA about care that needed to be provided. She further stated that she removed a pillow from under resident's legs prior to providing AM care and if she doesn't know the resident well, she looks at the CP.The policy, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated April 2007, included that the nurse will assess and document the location and current treatments, including support surfaces. The policy, Pressure Ulcer Treatment, dated December 2007, included review of the CP to assess for any special needs of the resident. The Prevention of Pressure Ulcers, dated March 2005, indicated Review the resident's care plan to assess for any special needs, shoes should be monitored for proper fit to avoid development of blisters, corns and calloused areas and when in bed, every attempt should be made to "float heels" (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by a therapist or prescribed by the physician. NJAC 8:39-27.1(a)(e)

Based on observation, interview and record review, it was determined that the facility failed to; a.) develop and revise interventions for residents who had a history of [REDACTED].) develop care plan interventions to manage residents with maladaptive behavior, which included non-directed wandering, verbal abuse to other residents and self-injuring behavior. This deficient practice was identified for 8 of 34 residents reviewed for care plan interventions, Resident #4, #5, #6, #9, 13, #14, #20, and #24. The failure of the facility to develop an effective behavior management plan and interventions resulted in a resident (Resident #6) self inflicting harm to herself by scratching and clawing to create large, open, bleeding, [MEDICAL CONDITION] on her face and ears. These deficient practices were evidence as follows: 1. During the initial tour on 5/30/12 at 10:00 a.m., the facility identified Resident #6 as having a behavior of picking at her skin. Throughout the survey from 5/30/12 to 6/4/12, the surveyor observed Resident #6 with open, bleeding, [MEDICAL CONDITION] on her face. The facility staff were aware of Resident #6's behavior of picking at her skin which resulted in open, draining, [MEDICAL CONDITION] and bleeding. On 5/31/12 at 10:45 a.m., the surveyor reviewed Resident #6's current plan of care which indicated that the problem of picking at his/her skin was not addressed. A care plan for the behavior was implemented on 6/4/12. (during the survey) 2. Resident #5 had the behavior of being abusive to her roommate. On 5/30/12 at 10:00 a.m., during the initial tour of the survey, the surveyor observed Resident #5 being verbally abusive to the roommate calling him/her a "[***] ," using racial slurs and threatening to kill him/her (roommate.) From 5/30/12 to 6/4/12, from approximately 9:00 a.m., to 12 noon, the surveyor observed Resident #5 being loud and verbally abusive to the roommate. The surveyor observed staff walking by Resident #5's room and failed to intervene. On 5/31/12 at 12:05 p.m., when the Resident #5 became very loud and could be heard throughout the unit, the surveyor observed staff closing the door, leaving both residents alone in the room. On 6/2/12 the surveyor reviewed Resident #5's care plan that addressed behavior and noted that interventions listed on the care plan for the behavior had not been carried out. The care plan indicated to use music therapy and activity. Resident #5 did not have a radio or any kind of music device in the room. Review of the medical record revealed that Resident #5 had not been attending activities for the past 2 months. 3. Resident #20 had a behavior of wandering into other resident's rooms. From 5/30/12 to 6/5/12 the surveyor observed Resident #20 wandering on all the units at various times. Resident #20 resided on Unit A. The surveyor observed Resident #20 wander from Unit A to Unit B, C, and D, continuously. On 5/31/12 at 10:30 a.m., the surveyor observed Resident #20 wheeling a food cart from Unit B to Unit C. The surveyor alerted a staff member as Resident #20 attempted to exit the unit. On 6/4/12 at 10:30 a.m., and 11:30 a.m., the surveyor observed Resident #20 entering and exiting an isolation room on Unit A. On 6/5/12 at 9:30 a.m., the surveyor observed Resident #20 wheeling a food cart from Unit C and attempted to exit the unit. An interview with the unit manager on 6/3/12 at 10:00 a.m., revealed that facility staff were aware of the wandering behavior since Resident #20's admission. On 6/3/12 at 10:30 a.m., the surveyor reviewed Resident #20's current plan of care and noted that there were no meaningful interventions that addressed the behavior. 4. The surveyor reviewed the medical record of Resident #13 on 5/31/12 at 10:00 a.m., which revealed the resident had [DIAGNOSES REDACTED]. Review of the care plan revealed that on 6/14/11 a goal was identified which stated "Weight will be stable +/- 5# x 90 days." There were no other revisions to the care plan to address the resident's current weight loss. An entry date 3/26/12, stated "update" and continue "POC." 5. Resident #24 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The surveyor reviewed the medical record for Resident #24 on 6/4/2012 at 12:30 p.m. The record indicated the Resident had an unplanned weight loss of 15 pounds during the period of 1/1/2012 through 5/14/2012. Review of the Care Plan for Resident #24 did not identify interventions to address the weight loss. 6. Resident #9 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. On 5/31/12 at 10:00 a.m., the surveyor reviewed the medical record of Resident #9, which revealed the following: According to Interdisciplinary Progress Notes (IDC), the resident had two falls on 10/16/11. The first fall was at 6:30 a.m., when the resident was found by the Certified Nursing Assistant (CNA) lying on the floor next to the bed. The resident was sent to the hospital for evaluation, returned to the facility at 1:00 p.m. and was placed in bed. The second fall occurred at 6:15 p.m. when the orderly found the resident lying on the floor. The IDC Progress Notes revealed that the resident was placed in a lounge chair by the nurses' station, for safety. On 10/18/11, the resident was returned to the use of the wheelchair. The facility was unable to provide a fall investigation for the 10/16/11 falls and there was no documented evidence that the new wheelchair intervention was added to the care plan. Further review of IDC Progress Notes dated 12/18/11, revealed Resident #9 fell at 5:35 a.m. The resident was found lying on the floor in her room, with no apparent injury. The facility was unable to provide an investigation of the incident. Review of the care plan revealed that there were no interventions added or revised following the incident. On 2/17/2012, Resident #9 fell at 1:15 p.m., when she mistakenly entered another resident's room. The CNA heard both residents talking loudly, heard a loud noise, went to investigate and found Resident # 9 sitting on the floor. On 6/1/2012 at 11:00 a.m., the surveyor requested the fall investigation. On 6/6/2012 the Director of Nursing (DON) provided the surveyor with an Incident/Accident Report dated 2/17/2012. The Intervention to Prevent Recurrence listed "Resident has chair & bed alarm, redirect PRN (when necessary)." The recommendation from the IDC Fall Meeting was to "continue with tab alarm on wheelchair and P.T. (physical therapy) screen." There was no evidence that the care plan interventions were revised after the fall. On 3/15/2012 at 11:45 p.m., Resident #9 was found sitting on the floor in front of her wheelchair. The Incident/Accident Report provided by the facility documented a recommendation to consider the use of a seatbelt for the wheelchair if there was an increase in the frequency of incidents. On 6/4/2012 at 10:00 a.m., the Unit Manager (UM) told the surveyor the use of a seatbelt had not been considered and there were no new interventions added to the care plan. On 5/11/2012 at 1:15 a.m., Resident #9 was found sitting on the floor in her room, complaining of severe pain in the right leg and hip. The resident was sent to the hospital for evaluation and was found to have a fractured right hip. Interventions to Prevent Recurrence listed on the Accident/Incident Report provided by the facility were to "continue alarms from before with checks on rounds by CNA." No new interventions were added to the care plan except another referral to PT, on return from the hospital. On 6/4/2012 at 10:30 a.m. the UM informed the surveyor that Resident #9 had another fall on 6/3/2012 at 6:45 p.m. Review of the Incident/Accident Report revealed the resident's alarm sounded and the resident was found in her room on the floor between the bed and the wheelchair. The Care Plan was updated on 6/4/2012 to include that the resident was not to be left alone in the wheelchair in her room and a non skid pad was applied to the wheelchair. Review of the resident's Treatment Administration Record (TAR) for April and May 2012 revealed "Non skid pad to wheel chair at all times - check for placement every shift" with an order date of 4/15/2011. There was no documented evidence that the facility identified the causal factors for the resident's frequent falls, reviewed the effectiveness of previous interventions, or revised the care plan to include new interventions to prevent further falls. 7. The surveyor reviewed the medical record of Resident #4 on 5/31/12 at 10:00 a.m., which revealed that the resident had a history of [REDACTED]. Further review of the medical record revealed that Resident #4 sustained falls in the facility on 9/12/11, 2/13/12 and 2/20/12. On 5/31/12 at 11:30 a.m., the surveyor reviewed Resident #4's medical record which indicated that the falls of 9/12/11 and 2/13/12 occurred during transfer. According to the investigative reports dated 9/12/11 and 2/20/12, Resident #4 fell while being transferred from the bed to the chair, with one person physical assist. There was no evidence that the facility revised interventions to prevent further accidents, after the above mentioned falls. On 6/1/12 the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for the resident. The CNA confirmed that Resident #3 was transferred from the bed to the chair with one person, physical assist. A review of Resident #3's current plan of care dated 9/12/11 revised 2/13/12, on 6/1/12 at 12:30 p.m., lacked evidence that the care plan was revised after each fall to determine if the resident required more than one person to assist with transfer. 8. Resident # 14 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. On 5/31/2012 at 10:00 a.m., the surveyor reviewed the medical record of Resident #14 which revealed the following: A Geriatric Psychiatry Consultation dated 4/23/2012 revealed Resident #14 had behaviors of paranoia with [MEDICAL CONDITION], arguing with peers and staff, talking constantly and verbal abuse. Review of the Care Plan for Resident #14 revealed that only Dementia with behavior disturbances and agitation were identified. The care plan did not include targeted behaviors and included only an intervention to redirect with diversional activities if possible, when anxious or agitated. On 5/31/2012 at 11:00 a.m., the UM told the surveyor that he was not aware if target behaviors were identified on the care plan. Refer to F224 for Resident #5 Refer to F309 for Resident #6 Refer to F323 for Resident #4, #9, #20 Refer to F325 for resident #13 NJAC 8:39-11.2(i)

Based on observation, interview and record review, it was determined that the facility failed to a.) provide care and treatment to a resident who had self-injuring behavior, and b.) administer treatment to a wound until 3 days after it was identified. Resident #6 continued to exhibit behaviors of picking at the face causing open sores and consistent bleeding. This deficient practice was identified for 2 of 5 residents reviewed for wound care, Resident #3 and #6, as evidenced by the following: 1. During the initial tour of the facility on 5/30/12 at 11:00 a.m., the nurse identified Resident #6 as having a behavior of picking at her skin. The surveyor observed the resident standing near the door of her room at that time. The resident's face was bleeding, and her hands were covered with blood. The nurse continued on the tour and did not intervene. On 5/30/12 at 12:30 p.m., the surveyor returned on the unit and observed that Resident #6 was eating her lunch. The resident's face was bleeding and some dry bloody drainage was noted on her neck area. Her left ear was bleeding and blood was dripping on her clothing. On 5/31/12 at 8:45 a.m., the surveyor observed Resident #6 in her room. The resident was eating with her right hand, her left hand was bloody, and bloody drainage was noted on the bed linen and the bedside table. A paper napkin was noted on the bedside table with bloody drainage and dry bloody scabs. On 5/31/12 at 9:15 a.m., the surveyor reviewed the resident's medical record, which revealed that the resident had [DIAGNOSES REDACTED]." Another entry dated 12/7/11 stated "OCD /picking skin, clipped fingernails, discussed not picking." Another entry dated 2/09/12 stated "scabs, Triple ABT oint (Antibiotic ointment) BID." A review of the Treatment Administration Record (TAR), on 5/31/12 at 12:45 p.m., revealed that the order for Triple Antibiotic ointment was never transcribed. The surveyor reviewed the TAR with the Infection Control Nurse who could not find a transcription for the Triple Antibiotic Ointment. Throughout the survey from 5/30/12 to 6/4/12, at various times, the surveyor observed Resident #6 with open, bleeding, [MEDICAL CONDITION] on her face and both ears. The resident's fingernails were long and jagged with dried blood under them. There was no documentation in the clinical record to indicate that treatment was provided. The clinical record lacked evidence that Resident #6 was evaluated to rule out other clinical conditions that could be responsible for the itching. On 6/1/12 at 10:00 a.m., the nurse told the surveyor that Resident #6 was evaluated by the psychiatrist and placed on [MEDICATION NAME] for itching. There was no evidence that the recommendation to keep Resident #6's fingernails trimmed was followed. According to information provided by the facility, Resident #6's fingernails were last cut and trimmed on 1/23/12. On 6/4/12 at 8:30 a.m., the surveyor entered the room with the Infection Control Nurse (ICN). The resident extended her hands, to show her fingernails and said to the ICN, "They are too long, I have been waiting for them to cut them." On 6/4/12 at 10:00 a.m., in the presence of the surveyor, the nurse measured the open [MEDICAL CONDITION] noted on Resident #6's face. The following measurements were recorded: Right ear lesion: 1 centimeter (cm) x 1 cm. Left facial lesion: 10 cm x 2 cm. Right cheek bone: 1 cm x 1 cm. Left facial lesion: 0.5 x 2 cm. 2. During the initial tour of the facility on 5/31/12 at 10:30 a.m., the surveyor observed Resident #3 in bed. The resident had a dressing on the right foot. The nurse told the surveyor at that time that Resident #3 had a vascular wound on the right foot. The nurse further stated that Resident #3 had a [MEDICAL CONDITION] (MRSA) in the wound. On 6/4/12 at 11:15 a.m., the surveyor observed the nurse perform a dressing change to the resident's right ankle wound. The nurse removed the soiled dressing and cleansed the right ankle wound. Below the right ankle wound, another open and necrotic area was noted. The nurse did not provide any treatment to the second wound. The resident's left foot was noted to be swollen and reddened. The nurse completed the dressing change, covered the right ankle wound and left the room. On 6/4/12 at 12:15 p.m., the surveyor reviewed the Treatment Administration Record (TAR) and noted that there was no treatment order for the second wound. At 12:30 p.m., the surveyor interviewed the nurse who revealed that the necrotic area below the right ankle wound was first observed on 6/2/12, (two days prior), during a dressing change. On 6/4/12 at 12:45 p.m., the surveyor reviewed the Interdisciplinary Notes from 6/2/12 to 6/4/12. There was no documentation regarding the second wound. The surveyor reviewed the Physician's Progress Notes which did not contain an entry regarding the second wound. On 6/4/12 at 2:00 p.m., the surveyor interviewed the Unit Manager who revealed that the physician was not notified of the second wound. On 6/4/12 at 2:30 p.m., the nurse measured the second wound and reported that the wound measured 4 centimeter (cm) x 2 cm. There was no evidence that the resident received any treatment for [REDACTED]. The wound was in direct contact with the soiled bed linen and the resident's clothing, and was observed to be draining bloody drainage. There was no evidence that the physician was notified of the second wound, until 6/4/12. On 6/4/12 at 6:00 p.m., the resident developed fever and chills and was admitted to the hospital with [REDACTED]. NJAC 8:39-27.1(a), 27.2(g)

Based on observation, interview and record review, it was determined that the facility failed to prevent/protect resident to resident verbal mistreatment. The verbal mistreatment inflicted by Resident #5 to Resident #34, resulted in psychological distress to Resident #34, causing the resident to cry in response to Resident #5's verbal tirades. This deficient practice was identified for 2 of 3 residents reviewed for abuse/mistreatment, Resident #5 and #34, as evidenced by the following: 1. On 5/30/12 at 10:30 a.m., during the initial tour of the facility, the surveyor overheard a resident shouting profanities and racial slurs. At that time, the surveyor observed Resident #5 seated in her room, next to the bed. In the right corner of the room, another resident was lying in a Geri chair. The other resident was later identified as Resident #34. Resident #5 was identified by the tour nurse as having a behavior of being loud and verbally abusive to the roommate. The nurse further stated " It is everyday, they go back and forth." The nurse continued on the tour and did not stop to re-direct the residents, or ask another staff member to re-direct Resident #5. Resident #34 was crying and kept saying "Mama, Mama, give me a little water, I did not do anything, why are you saying that." Resident #5 was heard to respond "Your Mother is dead, you killed your Mother, you [***] !" On 5/31/12 at 8:50 a.m., the surveyor observed Resident #5 in bed; she was again loud and verbally abusive to the roommate. Resident #34 would respond by crying and saying "Why are you saying this to me?" From 9:00 a.m., to 12:05 p.m., the surveyor sat at the nurses' station, and listened to Resident #5 shout profanities and racial slurs at Resident #34, as she sat and cried. That same day, at 12:05 p.m., Resident #5 became very loud. Her voice carried over from hallway B through the entire unit. The surveyor observed a CNA close Resident #5's door, leaving her behind closed doors, alone, with Resident #34, to whom she was screaming. There was no attempt made to redirect Resident #5's behavior or remove Resident #34, who was crying, from the room. On 5/31/12 at 12:30 p.m., the surveyor reviewed Resident #5's clinical record and noted that Resident #5 had been verbally and physically abusive to staff since 9/2011. On 5/31/12 at 1:15 p.m., the surveyor reviewed IDCP notes dated 5/17/12, which revealed that Resident #5 had been verbally abusive to Resident #34, her roommate. An IDCP note dated 5/21/12 revealed, "Continued to name call roommate and threatened to kill her." The nurse further wrote, "This behavior goes on the whole day." On 6/1/12 at 9:15 a.m., the surveyor reviewed another IDCP Note dated 5/24/12 which documented "Yelling continuously, daily, verbally abusive to roommate and staff ... " On 6/1/12 at 11:30 a.m., the surveyor reviewed a Psychiatrist Consult dated 5/24/12 which read, "Verbal tirades with racial and vulgar verbal tirades. Verbal abuse to peers, needs separation from group secondary to racial slurs. Mood mad, "I hate her (roommate)." Fluent clear speech normal rate and volume, little goal directed, screams repeatedly to roommate, "you are a [***] ." Recommendations: " Con't(continue) non pharmacologic interventions." On 6/1/12 at 12:30 p.m., the surveyor reviewed Resident #5's non pharmacologic interventions identified on the care plan for behavior. The care plan for behavior dated 5/18/12 documented, "Redirect negative behavior, allow time in a soothing environment, music therapy ... " None of these interventions were observed by the surveyor, as Resident #5 stayed in the room all day and shouted profanities at Resident #34. On 6/1/12 at 10:30 a.m., the surveyor attempted to interview Resident #5. The resident was very fearful and shouted " please don't hurt me," and she would not answer any questions. On the following dates the surveyor observed staff members in the hallway next to Resident #5's room. Resident #5 was loud and shouting racial slurs and profanities directed at Resident #34: 5/30/12 at 10:25 a.m., 5/31/12 from 9:00 a.m., to 12:30 p.m., 6/1/12 from 9:30 a.m., to 1:30 p.m., and 6/4/12 from 10:15 to 12:45 p.m., The was no attempt by staff to redirect the resident. A review of the activity attendance revealed that Resident #5 had not been in attendance for the last 2 months. On 6/1/12 at 12:45 p.m., the surveyor interviewed the CNA who cared for Resident #5. The CNA confirmed that Resident #5 screamed and yelled all day at the roommate, causing her to cry, and had been staying in the room. The CNA stated that the resident was wheel chair bound and unable to self- propel. On 6/5/12 at 9:30 a.m., (during the survey), Resident #5 was escorted to activity and participated without disturbances. Resident #34 was escorted to the sensory room for activity. On 6/5/12 at 1:30 p.m. (during survey), the Director of Nursing (DON) revealed that she witnessed the behavior and asked the Social Worker and nursing to implement a room change. The DON also stated that because Resident #5 was unable to propel her own wheel chair, she did not pose a physical threat to Resident #34. The DON further stated that the facility did have a vacant room, and that Resident #34 should not have been subject to that behavior. N.J.A.C.8:39-4.1a(5) (12)