Every finding on record at Elizabeth Nursing and Rehab Center

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 9/15/24 at 9:35 AM, the surveyor in the presence of the Chef observed the following during the kitchen tour: 1. The inside of the ice machine was observed in two areas with a black colored substance. The Chef stated the maintenance department oversees cleaning the ice machine and they were not aware of the black colored substance in the ice machine. On 9/15/24 at 12:34 PM, the surveyor conducted an interview with the Maintenance Director (MD), who stated the ice machine was cleaned monthly, normally the middle of the month. The MD was unable to state what the substance was or how long it had been there. On 9/17/24 at 9:45 AM, the Executive Chef (EC) provided the surveyor with a facility policy title, Cleaning Kitchen Equipment with a revised date of December 2023. Under the policy interpretation and implementation portion of the policy it states, 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair .11. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instruction and facility policy. On 9/17/24 at 1:38 PM, the surveyor team met with the Facility Operator, Assistant Licensed Nursing Home Administrator, Regional Administrator, Administrator in Training, and Director of Nursing and reviewed the above facility concerns. No additional information was provided. NJAC 8:39-17.2(g)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide a safe medical equipment (wheelchair with no armrest pad) which would provide additional support and comfort to protect the arm of a resident. This deficient practice was observed for one (1) of eighteen (18) residents (Resident #23) reviewed for assistant medical device. This deficient practice was evidenced by the following: On 9/15/24 at 11:38 AM, during initial tour, the surveyor observed Resident #23 who was seated in a high back wheelchair in the dayroom. The surveyor further observed the left-side armrest of the resident's high back wheelchair had no cushion. On 9/16/24 at 9:35 AM, the surveyor observed Resident #23 in the day room. The resident was groomed and dressed and was seated in their high back wheelchair which had no cushion on the left side armrest. A review of Resident #23's Admission Record revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), Hypertension (a condition in which the force of blood against the artery walls is too high), Major Depressive Disorder (persistent feeling of sadness or loss of interest that characterizes major depression can lead to a range of behavioral and physical symptoms) and Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities. A review of Resident #23's Quarterly Minimum Data Set (MDS) an assessment tool revealed the resident had a Brief Interview for Mental Status score of 00 out of 15, which indicated that the resident had severe cognitive impairment. On 9/16/24 at 9:40 AM, the surveyor in the presence of a Registered Nurse (RN) observed Resident #23 in their high back wheelchair. The RN acknowledged that the resident was missing their armrest cushion on the left side of the wheelchair. The RN stated that there must be cushion on the armrest of the resident's wheelchair. The RN further stated that the armrest cushion needed to be fixed. On 9/16/24 at 9:45 AM, the surveyor interviewed the resident's Certified Nursing Assistant (CNA) who acknowledged that the resident had no armrest cushion on the left-side of their wheelchair. The CAN stated that the resident should have an armrest cushion on both armrests. The CNA further stated that the armrest cushion for the wheelchair was inside the resident's room. On 9/16/24 at 9:50 AM, the surveyor observed the RN retrieved the armrest cushion from the resident's room and was observed snapping the cushion on the resident's wheelchair left armrest. The RN stated that she will contact the maintenance department to fix the resident's wheelchair. On 9/17/24 at 1:00 PM, the surveyor presented the above concerns to the facility administrative team which included the Licensed Nursing Home Administrator (LNHA), Assistant LNHA, Regional LNHA and the Director of Nursing (DON). No further information was provided. A review of the facility policy, Medical Equipment Management Plan (Created 08/31/24) and was provided by the DON revealed the following: 3 Maintains equipment operational plans to help assure reliability. 4. Develops procedures that establish intervals for the testing and maintenance of the equipment. 7. When problems are identified, actions are taken to resolve them. NJAC 8:39-27.1(a), 31.4(a),4.1(a)(12)

Based on observation, interview, and record review, it was determined that the facility failed (a). remove and dispose a discontinued medication (Namenda 5 mg) from the active inventory, this was identified for one (1) of four (4) residents, (Resident #85) observed during medication administration and (b). properly label, store, and dispose medications in two (2) of four (4) medication carts inspected. This deficient practice was evidenced by the following: a). On [DATE] at 9:05 AM, during morning medication pass observation, the surveyor observed a Licensed Practical Nurse (LPN# 1) preparing medications for Resident #85. LPN #1 opened the medication cart and pulled out a bingo card (a bubble pack which contained one dose of medication commonly used in long term care facilities) which contained Memantine (Namenda) 5mg tablets. The surveyor observed LPN #1 checked the resident's electronic medication administration record. LPN #1 stated that the resident was on Namenda 10 mg. She then investigated the medication cart and found another bingo card for Memantine (Namenda)10 mg tablets. LPN#1 stated that the Namenda 5 mg was for the evening dose. On [DATE] at 9:30 AM, during medication pass reconciliation the surveyor reviewed Resident #85's physician's orders (PO) which revealed that the resident's PO for Memantine 10 mg tablets were discontinued on [DATE]. The surveyor reviewed the medication record for Resident #85. A review of the resident's Admission record revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Hypertension (a condition in which the force of the blood against the artery walls is too high), Hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and Diabetes Mellitus (is a disorder in which the amount of sugar in the blood is elevated). A review of the Admission MDS dated [DATE], reflected the resident had a Brief Interview for Mental Status score of 15 out of 15, indicating that the resident was cognitively intact. A review of the [DATE] Order Summary Report (OSR) revealed a PO dated [DATE] for Memantine oral tablet 10 mg, give 1 tablet by mouth two times a day for Dementia. The [DATE] OSR report also showed that the resident had the following discontinued PO's: Memantine oral tablet 5 mg give 1 tablet by mouth two times a day for dementia which had a discontinued date of [DATE]. On [DATE] at 10:40 AM, the surveyor in the presence of LPN#1 reviewed Resident #85's medical records. LPN#2 acknowledged that the resident's Namenda 5 mg was discontinued on [DATE] and the medication should have been removed from the medication cart as soon as the medication was discontinued. b). On [DATE] at 10:50 AM, the surveyor inspected the first-floor medication cart in the presence of LPN#2. The surveyor observed an opened vial of Purified Protein Derivative (PPD) (a test that detects tuberculosis) that indicated an open date of [DATE] and was stored inside the medication cart. The surveyor also observed an unopened pen of Basaglar insulin that was undated and stored inside the medication cart. The surveyor interviewed LPN#2 who acknowledged that the PPD vial and the unopened pen of Basaglar should have been stored inside the medication refrigerator. On [DATE] at 11:00 AM, the surveyor inspected the 2nd floor medication cart in the presence of LPN#3. The surveyor observed an opened Timolol 0.5% (glaucoma) eye drops that had an opened date of [DATE] and was expired. At that time, the surveyor interviewed LPN#3 who stated that the Timolol eye drops, once it's opened had a 28-day expiration date. LPN#3 acknowledged that the Timolol eye drops was expired and should have been removed from the medication cart. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. PPD vial should be stored in the refrigerator. 2. Unopened Basaglar insulin pen should be stored in the refrigerator 3. Timolol eye drops once opened has an expiration date of 28-days. On [DATE] at 1:00PM, the surveyor presented the above concerns to the facility administrative team which included the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), assistant LNHA, and the Regional LNHA. There was no additional information provided. A review of the facility's policy titled Medications Destruction dated [DATE] and provided by the DON included the following: When non controlled medications are expired or discontinued, all medications in their original packaging are returned to the pharmacy for proper disposal. A review of the facility's policy titled Medication Storage dated [DATE] and provided by the DON included the following: 5. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. 6. Medications will be stored at the appropriate temperature in accordance with pharmacy and /or manufacturer's labeling. NJAC: 8:,d+[DATE].4 (a) (h) (d)

Based on observation, interview, record review and review of facility provided documentation, it was determined that the facility failed to provide a comprehensive nutritional assessment to identify the nutritional needs of newly admitted and readmitted residents to the facility within a 14 day period as required by Centers of Medicare & Medicaid Services (CMS). This deficient practice was identified for 4 of 9 newly admitted / readmitted residents reviewed for nutritional assessments between 3/28/23 to 4/17/23, (Resident #231, 232, 233, and 234), and was evidenced by the following: The surveyor reviewed the Resident Admission List supplied by the Admission's Director for residents admitted or readmitted to the facility from 3/28/23 to 4/17/23 with the following findings: 1. On 5/3/2023 at 11:05 AM, the surveyor observed Resident #231 in bed. The resident stated that they were experiencing tooth and jaw pain on the left side of their mouth. The facility was providing soft food, but the resident stated that they had not been seen by the Registered Dietitian (RD). On 5/3/2023 at 11:15 AM, during review of Resident #231's Electronic Medical Administration Record (e-MAR) and Face sheet (FS) (an admission summary sheet), the documented initial admitted (IAD) was 3/28/2023. Continued review of the medical records, revealed that the comprehensive nutritional assessment was created on 4/25/2023, 14 days late, after the 14-day period required by CMS. 2. On 5/3/2023 at 11:30 AM, during review of Resident #232's e-MAR and FS, it was revealed that the resident had an IAD of 4/3/2023 and that the comprehensive nutritional assessment was created on 4/25/2023, 8 days late, after the 14-day period required by CMS. 3. On 5/3/2023 at 11:50 AM, during review of Resident #233's e-MAR and FS, it was revealed that the resident had an IAD of 4/2/2023 and that the comprehensive nutritional assessment was created on 4/25/2023, 9 days late, after the 14-day period required by CMS. 4. On 5/4/2023 at 10:30 AM, during review of Resident #234's e-MAR and FS, it was revealed that the resident had a re-admitted [DATE] and the comprehensive nutritional assessment was created on 4/25/2023, 3 days late, after the 14-day period required by CMS. On 5/5/23 at 11:32 AM, the surveyor interviewed the RD, who has been working at the facility since 2019. The RD stated they try to get all initial nutrition assessments completed within 72 hours of arrival to the facility regardless of initial or re-admission. The RD further stated she was on vacation from 3/29/23 to 4/19/2023. The facility failed to have a covering RD during this period of time creating a delay in the comprehensive nutrition assessments for Residents #231, 232, 233, and 234. All the comprehensive nutrition assessments for these residents failed to be completed within the 14-day required period. On 5/8/2023 at 11:37 AM, the RD provided the surveyor with a policy titled, [NAME] nursing Nutrition Assessment Guidelines with a revised date of 12/2019. Under the Policy Explanation and Compliance Guidelines, the policy states: 2. The Dietician will complete a nutrition assessment on residents admitted to the facility. On 5/10/23 at 1:35 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) to discuss the above mentioned concerns. No further relevant information was provided. N.J.A.C. 8:39-11.2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) store, label, and date potentially hazardous foods to prevent food-borne illness On 5/3/23 at 9:30 AM, the surveyor entered the facility kitchen and asked to tour with the Food Service Director (FSD), but the FSD was not in the facility, the tour began with the available Chef Supervisor (CS). At this time, the surveyor and CS toured the kitchen and observed the following: 1. In the Refrigerator/Freezer combo located in the dry storage area, the surveyor observed in the refrigerator a 48-ounce container of Ricotta cheese with a written date of 4/24. The CS could not state if that date was the received, open, or discard date. The CS did acknowledge that once opened the Ricotta should be discarded within 5 days but could not explain why the container had not been disposed of. The CS opened the container and upon further inspection the surveyor observed multiple green colored debris inside the container. The CS was unable to state what the debris was, container was discarded. 2. In the freezer section of the Refrigerator/Freezer Combo, the surveyor observed an open bag of frozen mixed vegetables and an open bag of frozen rolls both without any dates. At that time the FSD joined the surveyor and CS on the tour. The FSD could not explain why the two items in the freezer were not dated, but acknowledged all items need to have a received, opened and discard dates. The FSD provided a facility policy titled, Checking Daily Refrigerator For Appropriate Storage that was reviewed by the surveyor. Under policy, it states, All foods stored in the daily refrigerator will be checked to ascertain that they are stored in a manner that assures that they are appropriate for use and free from potential cross-contamination. On 5/10/23 at 1:30 PM, the surveyor discussed the above concerns with the FSD, Director of Nursing (DON), and Assistant Licensed Nursing Home Administrator (ALNHA). No further information was provided. NJAC 8:39-17.2(g)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a recommendation made by the Consultant Pharmacist was acted upon in a timely manner. This deficient practice was identified for 1 of 6 residents reviewed for medication management (Resident #6). The evidence was as follows: On 4/26/21 at approximately 10:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #6 goes to the [CONDITION(S)] center three days a week due to end stage [CONDITION(S)]. On 4/27/21 at 9:42 AM, the surveyor observed Resident #6 sitting on the edge of the bed talking on the phone. The resident was unable to be interviewed at that time. The surveyor reviewed the medical record for Resident #6. A review of the Admission Record (face sheet) reflected that the resident was admitted to the facility with diagnoses which included end stage [CONDITION(S)] and dependence on renal [CONDITION(S)] (the process of removing excess water, solutes, and toxins from the blood due to impaired functioning of the kidneys.). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/23/21 reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating a fully intact cognition. A review of the resident's individualized care plan dated 7/7/2020 included that the resident had end stage [CONDITION(S)] and was receiving hemodialysis treatments at the [CONDITION(S)] center three times a week on Monday, Wednesday and Friday. Interventions included to administer medications as ordered .and monitor for compliance. A review of the Physician's Order Form for April 2021 reflected a physician's order (PO) dated 1/10/2020 for a medication to control high blood pressure, [MEDICATION(S)]. The order specified to give [MEDICATION(S)] 25 milligrams (mg) one tablet by mouth on [CONDITION(S)] days Monday, Wednesday and Friday at 5 AM and 5 PM, and hold for systolic blood pressure (SBP; top number on a blood pressure reading) of less than 130 or heart rate less than 60 beats per minute. A review of the Medication Administration Record (MAR) for April 2021 reflected the corresponding PO dated 1/10/2020 for the [MEDICATION(S)] 25 mg by mouth at 5 AM and 5 PM on [CONDITION(S)] (HD) days. The April 2021 MAR reflected that the resident consistently refused the [MEDICATION(S)] 25 mg for the 5 AM dose. The back of the MAR was signed that the resident had refused the [MEDICATION(S)] at 5 AM every Monday, Wednesday and Friday when it was due and that he/she had continued to refuse it despite three attempts to administer it. The surveyor reviewed a Consultant Pharmacist (CP) recommendation dated 1/27/21 which reflected, The Medication Administration Record indicates frequent refusals of [MEDICATION(S)] at 5am prior to [CONDITION(S)]. Please evaluate current order. The CP recommendations had a print out section for the physician to accept or not accept the recommendation and a reason for not accepting if indicated. The form was blank and there was no evidence it was addressed. A review of a subsequent handwritten monthly CP recommendation dated 2/24/21 indicated [MEDICATION(S)] refusals continued. A review of the electronic Progress Notes (ePN) from 1/27/21 to 4/28/21 reflected that the CP recommendations dated 1/27/21 and 2/24/21 did not address the recommendations with the physician regarding the resident refusing the [MEDICATION(S)] at 5 AM before the [CONDITION(S)] days. On 4/28/21 at 11:30 AM, the surveyor interviewed the resident's assigned LPN. The LPN stated the CP comes monthly but that she was not responsible for reviewing for the CP recommendations. She stated that the CP sends all recommendations to the Director of Nursing (DON), and the DON delegates it further to the evening Nurse Supervisor. The surveyor and the LPN reviewed the resident's MAR for April 2021, and the LPN acknowledged that the resident routinely refused the 5 AM dose of [MEDICATION(S)] before going to [CONDITION(S)]. The LPN stated that the resident always refused it but just on the days that he/she goes to the [CONDITION(S)] center. The LPN acknowledged that usually after three consecutive times of refusing a medication, that the Attending Physician (MD) needed to be notified. She could not speak to if the MD had been notified. The LPN stated that Resident #6 was scheduled to go to an initial cardiologist appointment on 5/5/21 at 2:15 PM and that she believed that it was possible the physician did not want to change around the medication until he/she was seen by the cardiologist next week. The LPN confirmed that she didn't think that it was documented, but that she would look into it. The LPN couldn't speak to why the resident was refusing the [MEDICATION(S)], so the surveyor and LPN went to interview Resident #6. At 11:34 AM, the surveyor observed Resident #6 sitting on the edge of the bed. The resident stated in the presence of the LPN and surveyor that he/she refuses the [MEDICATION(S)] dose at 5 AM every morning because her Renal Doctor at the [CONDITION(S)] center told me to not take it before [CONDITION(S)]. The resident added that it was because the blood pressure had dropped a while ago and that he/she was not comfortable taking it again. The resident stated that the nurse keeps bringing it at 5 AM, but that he/she does not take it but takes all the other morning pills before [CONDITION(S)]. On 4/28/21 at 12:04 PM, the surveyor conducted a phone interview with the CP. The CP stated that he was out on leave during January and February 2021 and could not speak to the recommendations for the [MEDICATION(S)]. However, he stated that if recommendations were made in January 2021 and again in February 2021 due to the frequency or pattern of refusing a particular medication, that there should be documentation to rationalize why it was not being accepted, if the resident was still refusing it in April 2021. He stated that he documents all irregularities on the monthly review and the reviews get send to the DON. The physician was allowed to not accept the CP recommendation but that there should be a documented rationale. He could not speak to the resident's refusal of [MEDICATION(S)] without looking at his/her chart. He stated that he didn't have the resident's medical record accessible. On 4/29/21 at 10:52 AM, the surveyor interviewed the evening Nurse Supervisor and the DON in the presence of the survey team. The DON acknowledged that the CP recommendation had not been addressed and was unable to provide documented evidence that it had been addressed by the MD. She stated that after surveyor inquiry, the Nephrologist (Physician that specializes in kidney/renal impairments) was notified and that they had recommended to change the 5 AM dose to be given at around 12 PM when the resident returned from the [CONDITION(S)] center. She confirmed that the resident's blood pressure fluctuated due to his/her fluid imbalances associated with the kidney impairments, but that he/she was seeing the Cardiologist next week who would also review the medication. The evening Nurse Supervisor acknowledged in the presence of the survey team that she had missed those recommendations since January 2021 until surveyor inquiry but that after three consecutive refusals of a medication, that the nurse should have called the Attending Physician for new orders or changing the order time as well. At 12:06 PM, the Assistant Licensed Nursing Home Administrator (LNHA) provided the surveyor a copy of the Consultant Pharmacist role revised 1/15/19, which included that the CP would provide appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated. A review of the Medication Administration policy revised 2018, included that If a Resident/Patient refuses the medication, the physician is to be notified and a Licensed Nurse's note will be completed. No additional policy or procedure was provided on acting on Consultant Pharmacist recommendations. NJAC 8:39-29.3

Based on observation, interview, and review of facility documents, it was determined that the facility failed to: a.) report to the New Jersey Department of Health (NJDOH) an allegation of resident to resident abuse that occurred on 3/2/21 and b.) develop the facility's Abuse Prevention, Identification and Investigation policy in accordance with federal and state requirements for the timing of reporting such allegations of abuse to the state agency. The deficient practice was identified for 1 of 1 investigations of reportable incidents reviewed (which occurred between Resident #2 and #37) and was evidenced by the following: On 4/27/21 at 1:00 PM, the surveyor requested from the Director of Nursing (DON) any events that occurred in the past six months. The DON stated that the facility had no reportable incidents. The surveyor then requested for any investigations involving allegations of abuse or injury of unknown origin. On 4/28/21 at 9:04 AM, the surveyor reviewed the investigation provided by the DON involving Resident #2 and #37. The investigation reflected that on 3/2/21 at 3:30 AM, staff heard screaming and crying coming from Resident #2 and #37's room. Upon entering the room, the nurse and Certified Nursing Aide (CNA) observed Resident #2 standing at Resident #37's bedside yelling at their significant other. Resident #37 was crying and reported to staff that Resident #2 was yelling and threatening him/her and was attempting to hit them. Staff tried to redirect Resident #2, but he/she became combative and belligerent with staff. The residents were then immediately separated and currently reside in two separate rooms and on two different resident care units/floors. On 4/28/21 at 11:33 AM, the surveyor interviewed the DON who stated that she was in charge of investigations and reporting to the NJDOH. The DON stated that she would report to the NJDOH any injury of unknown origin and verbal or physical abuse within 24-72 hours depending if the incident occurred during a weekday or weekend. The DON stated that since she had been at the facility for the past ten months, she had experienced no allegations of abuse, but there was a romantically involved couple who he/she was screaming at his/her significant other, but that was not abuse because they were in a relationship. She added that Resident #2 was confused and did not intend to harm their significant other. When asked, the DON confirmed that yelling and threatening to hit someone would be considered verbal abuse. A review of the facility's Abuse Prevention, Identification and Investigation policy dated revised 1/2020 included that all incidents of abuse or suspected abuse are reported to the appropriate agencies within twenty-four hours of the incident. On 4/29/21 at 10:42 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Assistant LNHA, DON, Administrative team, and the survey team stated that upon investigation, the facility determined there was no physical injury to Resident #37 so at the time they did not see a no reason to report the incident to the NJDOH because Resident #2 was only verbally threatening the resident. The Assistant LNHA stated that the feeling was that since there was no physical injury, the incident did not need to be reported, but acknowledged that the facility should have reported the investigation in to the NJDOH for the verbal abuse. At this time, the DON stated that the facility used the NJDOH Reportable Events Grid to determine what incidents needed to be reported and the timeframe for reporting. The DON stated that allegations of abuse should be reported to the NJDOH within twenty-four hours. The DON confirmed she was in charge of the facility's abuse policy and she would review the NJDOH Reportable Events Grid with the facility's abuse policy. On 4/29/21 at 11:43 AM, the DON acknowledged that abuse was to be reported to the NJDOH immediately, but no later than two hours in accordance with the grid she had in her procession. She stated that she would have to update the facility's policy to reflect the same. NJAC 8:39-4.1(a)5

Based on observation, interview and review of the medical record and review of other facility documentation, it was determined that the facility failed to adequately monitor the target behaviors for the use of [CONDITION(S)] medications (mood altering medications) for 2 of 5 residents (Resident #2 and Resident #17) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 4/27/21 at 9:03 AM, during initial tour of the first-floor nursing unit, the surveyor observed Resident #2 seated in the first-floor dining room with a breakfast tray on the table in front of the resident. On 4/27/21 at 9:22 AM, the surveyor reviewed Resident #2's medical record which revealed that the resident was admitted to the facility with diagnoses which included, but not limited to, [CONDITION(S)], unspecified dementia without behavioral disturbance and hypertension (high blood pressure). The Physicians Order Form revealed a physician's order dated 3/2/21, Start [MEDICATION(S)] [an antipsychotic medication] 12.5 mg P.O. [by mouth] BID [twice a day] for mood disorder. Further review of another Physicians Order Form revealed an order dated 3/17/21, D/C [discontinue] [MEDICATION(S)] 12.5 mg P.O. BID, Start [MEDICATION(S)] 12.5 mg P.O. Q AM [every morning] and [MEDICATION(S)] 25 mg P.O. Q 6PM [every day at 6 pm]. The Physician's Order Set (POS) for April 2021 revealed an order dated 8/20/20, [MEDICATION(S)] (an antidepressant medication) 20 mg one (1) tablet by mouth once daily for depression. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/22/21 reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated the resident had a severely impaired cognition. A further review of the MDS, indicated that the resident received [CONDITION(S)] medications on 7 out of the last 7 days during the look-back period. At 10:13 AM, the surveyor reviewed Resident #2's Medication Administration Record (MAR) located in a three-ring binder on the nursing unit's medication cart. The surveyor did not observe a Behavior/Intervention Monthly Flow Record (BIMFR), a tool used to record the number of episodes of target behaviors that occur each day to monitor the use of [CONDITION(S)] medications, for the month of April 2021. The surveyor then asked the Registered Nurse (RN) where Resident #2's BIMFR was located. The RN looked in the resident's medical record and MAR and confirmed that Resident #2 did not have a BIMFR for the month of April 2021. The RN then stated that the resident should have a BIMFR since the resident was on [MEDICATION(S)]. The RN then spoke to the Assistant Director of Nursing (ADON) regarding the missing BIMFR. The ADON stated that the facility was transitioning to the electronic health record and that there should be nurses notes when the resident has a behavior. At 11:03 AM, the RN provided the surveyor with the electronic nurses notes (eNN) and stated that staff write a behavior note in the eNN and monitor behaviors that way. The RN then confirmed that some of the residents had a BIMFR that came from the pharmacy. The RN could not give the surveyor a reason why Resident #2 did not have a BIMFR for the month of April. At 12:55 PM, the surveyor asked the Nursing Supervisor (NS) what the process was to monitor residents that are prescribed [CONDITION(S)] medications. The NS stated that a resident's behaviors are monitored on a daily basis and that the facility uses a flow sheet that indicated what target behaviors are to be monitored. The NS then stated that if the resident exhibited a different behavior from the listed target behavior, then the nurse would document the different behavior in the eNN. The NS stated that any resident that was prescribed an anti-psychotic medication or an antidepressant medication should have a BIMFR with their target behavior that needed to be monitored written on the BIMFR. The surveyor then asked the NS to view Resident #2's MAR and the NS confirmed that Resident #2 did not have a BIMFR for April 2021. There was no documented evidence that a BIMFR was created to monitor any target behavior for Resident #2's antipsychotic medication and antidepressant medication for the month of April. The NS could not give the surveyor a reason why Resident #2 did not have a BIMFR for the month of April. The NS stated that a BIMFR should have been started by a nurse when the new medication [[MEDICATION(S)]] was prescribed. The NS further stated that if a pre-printed BIMFR for [MEDICATION(S)] did not come from the pharmacy that the facility had blank forms and that a nurse should have handwritten a BIMFR when the new month started. The surveyor then asked the NS to locate Resident #2's MAR from March 2021 for the surveyor to review. At 1:24 PM, the NS provided the surveyor Resident #2's March 2021 MAR which included a BIMFR for Resident #2's antidepressant medication [MEDICATION(S)]. The surveyor reviewed the March 2021 BIMFR which revealed the following: Under Psychoactive Medication/Dosage typed in was [MEDICATION(S)] tab 20 mg, under Behavior handwritten under 1 was Isolation and under 2 was Feeling sad. There was a section for each shift of each day of the month to document if the behavior occurred. There was no documented evidence that a BIMFR was created to monitor any target behavior for [MEDICATION(S)] when the medication was started on 3/2/21. On 4/29/21 at 11:10 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #2 should have had a BIMFR with target behavior(s) listed for the resident's antidepressant medication for the month of April and antipsychotic medication for the month of March and April 2021. 2. On 4/27/21 at 9:00 AM, during initial tour of the first-floor nursing unit, the surveyor observed Resident #17 sleeping in bed. At 10:45 AM, the surveyor reviewed Resident #17's medical record which revealed that the resident was admitted to the facility with diagnoses which included, but not limited to, [CONDITION(S)] (irregular heart rate), unspecified dementia with behavioral disturbance and hypertension. The POS for April 2021 revealed the following physician orders: an order dated 8/26/20, [MEDICATION(S)] [an antidepressant medication] 5 mg three (3) tabs [15 milligrams (mg)] by mouth once daily for depression and an order dated 5/16/19, [MEDICATION(S)] [an antidepressant] 15 mg one (1) tablet by mouth at bedtime for depression. A review of the quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 14 out of 15, which indicated the resident had an intact cognition. A further review of the MDS, indicated that the resident received [CONDITION(S)] medications on 7 out of the last 7 days during the look back period. At 11:23 AM, the surveyor reviewed Resident #17's MAR for April 2021 located in a three-ring binder on the nursing unit's medication cart. The surveyor did not observe a BIMFR for the month of April 2021. The surveyor then asked RN#2 where Resident #17's BIMFR was located. RN#2 reviewed Resident #17's MAR and medical record and confirmed that Resident #17 did not have a BIMFR for the month of April 2021. RN#2 could not give the surveyor a reason why Resident #2 did not have a BIMFR for the month of April 2021. At 1:29 PM, the surveyor asked the NS to view Resident #17's MAR and the NS confirmed that Resident #17 did not have a BIMFR for April 2021. There was no documented evidence that a BIMFR was created to monitor any target behavior for Resident #17's antidepressant medications for the month of April. The surveyor then asked the NS to locate Resident #17's MAR from March 2021 for the surveyor to review. At 1:24 PM, the NS provided the surveyor Resident #17's previous month's March 2021 MAR which included two BIMFRs for Resident #17's antidepressant medications. The surveyor reviewed the March 2021 BIMFR which revealed the following: On the first BIMFR, under Psychoactive Medication/Dosage typed in was [MEDICATION(S)] tab 5 mg, under Behavior handwritten under 1 was Restlessness and under 2 was Suicidal thought. On the second BIMFR, under Psychoactive Medication/Dosage typed in was [MEDICATION(S)] tab 15 mg, under Behavior handwritten under 1 was Refuse OOB (out of bed) and under 2 was Crying. On 4/29/21 at 11:11 AM, the surveyor interviewed the DON in the presence of the survey team who stated that Resident #17 should have had a BIMFR with target behavior(s) listed for the resident's antidepressant medications for the month of April. She acknowledged that without that form, the facility did not have another consistant way to track target behaviors for each of the medications. She confirmed that without the tracking it would be difficult to determine if a gradual dose reduction could be attempted in the future. The DON stated that the facility had been working on the [CONDITION(S)] medication management during their Quality Assurance Program Improvement plans, and that this was the first time that missing behavior monitoring sheets were identified. The surveyor reviewed the undated facility provided policy titled, [CONDITION(S)] Drug Usage which included the following: Policy: It is the policy of this facility to maintain a chemical free environment. However in the event a [CONDITION(S)] drug/agent must be used, this facility shall implement a system to assure proper use, monitor side effects and assess the usage that the least means is being used with the ultimate goal in reduction or elimination. Psychoactive drug therapy will be used only to enhance the quality of life of the resident and not as a punishment or for the convenience of staff or as a substitute for other appropriate treatment, or in quantities that interfere with the resident's treatment program. Definition: [CONDITION(S)] drugs/agents are organic or inorganic substances which have the ability to alter mental, emotional or behavioral disorder. They are classified in three (3) groups: 1) ANTI-PSYCHOTIC- a substance that is used in managing the manifestation of psychotic disorders. 2) ANTIDEPRESSANT- a substance use in treating emotional disorders and depression . Procedure: .5. All residents started on psychoactive medications or having dosage or drug change will be closely observed and monitored for one (1) week. 6. A Psychoactive Drug Flow Sheet' (see Attachment B) will be initiated to monitor behavior and/or side effects. This form must be continued as long as the medication is being used . N.J.A.C. 8:39-27.1 (a)

Based on observation and interview on 4/26/21, it was determined that the facility failed comply with the minimum square footage requirements for private and semi-private resident bedrooms for 4 of 4 resident rooms (Room 227, 230, 231, and 232). This deficient practice was evidenced by the following: During a tour of the building in the presence of the facility's Maintenance Director from 10:30 AM to 1:30 PM, the surveyor observed three 2-bedded resident bedrooms were less than 80 square feet per bed or 160 square feet total. This was noted for resident rooms 230, 231 and 232 which measured 14.5-ft. x 10-ft. for a total of 145 square feet. Also, one private room (single bed) was less than 100 square feet. Resident room 227 measured 9.5-ft. x 9-ft. for a total of 85.5 square feet. These findings were confirmed by the facility's Maintenance Director in an interview during the tour of the building. Also, the facility's Administrator acknowledged these findings during the Life Safety Code exit conference at 1:30 PM. Resident rooms 230, 231 and 232 were not occupied at the time of survey. The facility's Administrator indicated in an interview at 1:30 PM that these rooms had been converted to special isolation/observation rooms during the current Covid-19 pandemic and the residents were moved to other semi-private rooms in the facility. Resident room 227 was occupied at the time of survey. The facility administration was notified that they could not re-occupy the vacant resident rooms: Room 227, 230, 231, and 232, with more than one resident. NJAC 8:39-31.2(e)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) staff were appropriately screened prior to entrance to the facility to limit the potential spread of COVID-19, b.) closely monitor a resident, in accordance with the resident's care plan, when a resident entered into a quarantine unit; and, c.) staff doffed (removed) personal protective equipment (PPE) and performed hand hygiene (HH) before exiting a COVID-19 isolation unit. This deficient practice occurred for 2 of 3 units toured and was evidenced by the following: 1. On 07/15/20 at 8:40 AM, two surveyors entered the facility lobby. They observed that a female entered the lobby and used an infrared thermometer to take her temperature, and she then proceeded to exit the lobby. The Director of Nursing (DON) then proceeded to take the surveyors' temperature with an infrared thermometer and instructed the surveyors to complete a screening form before entry into the facility. The DON stated the screening form has to be filled out to ensure COVID doesn't spread. She said a person should not enter the facility without filling out the screening form. She stated a staff member should then review the screening form answers before allowing entry into the facility. At that time, the surveyor completed the required COVID-19 Employee Screening Log. The name entry directly above the surveyor's entry did not have the yes or no questions for cough, sore throat or breathing difficulties completed. At that time, the surveyor interviewed the DON regarding the incomplete entry and the observation of the person who entered the building. At that time, the DON reviewed the incomplete entry screening form, located above the surveyor's entry, and identified the person as a part-time dietitian. The DON further stated, she cannot do that, she should have filled out all questions on the screening completely when she entered the building. At 8:50 AM, the dietitian emerged into the lobby area, and the DON stated to her, you know you need to fill this out, you were told to do that already. 2. On 07/15/2020 at 12:15 PM during a tour of the second floor Persons Under Investigation (PUI) unit, the surveyor observed Resident #1 enter the unit via the closed double doors that separated the PUI unit from the persons who are recovered from COVID unit. The resident was improperly wearing a mask, nose exposed and ambulated directly past a Licensed Practical Nurse (LPN) who was standing at a medication cart. The resident proceeded directly through the hallway toward and un-used room. During this observation the resident was heard using profanity directed toward the nurse about wearing a mask. The resident then entered the un-used room and exited through doors located in the room that led to an enclosed outdoor balcony. At 12:19 PM, the surveyor, in the DON's presence, observed Resident #1 sitting in a chair located on the enclosed balcony. The surveyor interviewed the DON regarding if the resident was allowed on the PUI unit, and if the resident was required to wear additional PPE, such as a gown, mask, or gloves. The DON stated Resident #1 does not need to wear additional PPE because the resident was PUI/recovered and was just passing through. The DON said the resident could be combative, so the resident just goes when (the resident) wants. At 12:30 PM, the surveyor interviewed the LPN who stated Resident #1 is not PUI and is recovered but they let the resident go on the balcony to see family who comes to the parking lot below the balcony. The LPN clarified for the surveyor that they referred to the facility. A review of the admission record for Resident #1 revealed the resident had [DIAGNOSES REDACTED]. Review of the care plan for Resident #1 revealed: under Problem, initiated 06/30/2020, Resident is non-compliant with quarantine guidelines due to altered mental status. Ambulated throughout unit during the day. The goal, initiated 07/15/2020, Resident will not sustain injury, or infection (result to) non-compliance and roaming of hallways. The interventions included, date initiated 06/30/20, resident will be monitored closely when leaving (his/her) room. Will wear face mask once out of the room at all times. Will be reminded to put the face mask on. At 12:30 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the resident had tested positive for COVID-19 in the past, has recovered and currently resided on the Recovered unit. The LPN said the resident visited with his/her family daily from the outside balcony. At 2:25 PM, the surveyors interviewed the Assistant Director of Nursing (ADON), who stated Resident #1 was supposed to be monitored, and that the resident was difficult to redirect. 3. At 12:35 PM on the PUI unit, the surveyor observed the Housekeeping Director (HKD), exit through the plastic divider that separated the COVID positive unit from the PUI unit and contained one COVID positive resident. The HKD was observed wearing a gown, an N95 mask, but was not wearing gloves. He held a phone in his un-gloved hand, and without doffing PPE and performing hand hygiene (HH) exited the COVID positive unit. At 12:40 PM, the surveyor interviewed the HKD, who stated he was cleaning the floors in an un-occupied room located on the COVID positive unit. Since he did not go into the COVID positive resident room, he didn't need to do anything. He stated he needed to take a phone call. At 2:36 PM, the surveyors interviewed the consultant infection preventionist, who stated that the HKD should have worn a gown, an N95 mask, gloves, and a face shield. She noted that nobody should be in the COVID positive unit without the full PPE, and the PPE should be doffed before leaving the unit. The surveyor interviewed the ADON regarding if the HKD was provided with education regarding PPE. The ADON could not provide any documented education provided to the HKD on donning and doffing of PPE. Review of the Outbreak Response Plan, effective 05/15/20, revealed implementing control measures based on signs, symptoms, diagnosis, mode of transmission, and location in the center and measures may include screening all employees for elevated temperatures and signs/symptoms. Review of the Personal Protective Equipment Policy dated 4-2020 revealed PPE must be removed slowly and deliberately in a sequence that prevents self-contamination and hands are washed. An alcohol-based hand sanitizer is used immediately after removing all PPE. N.J.A.C. 8.39-19.4(a)

Based on interview and record review, it was determined that the facility failed to submit the Minimum Data Set (MDS) assessments in a timely manner. This deficient practice was identified for 14 or 21 residents reviewed for MDS timeliness (Resident #1, #2, #3, #4, #5, #6, #9, #12, #13, #14, #15, #16, #17 and #25) and was evidenced by the following: On 7/16/19 and 7/18/19, the surveyor reviewed the most recent MDS's, an assessment tool used to facilitate the management of care, for the timeliness of submission for 14 system-selected residents. Information provided by the facility revealed the following for the 14 residents: 1. Resident #1 had an Assessment Reference Date (ARD) of 4/27/19. The assessment was completed on 5/11/19 and was not submitted until 7/14/19. 2. Resident #2 had an ARD of 4/28/19. The assessment was completed on 5/12/19 and was not submitted until 7/14/19. 3. Resident #3 had an ARD of 4/21/19. The assessment was completed on 5/5/19 and was not submitted until 7/14/19. 4. Resident #4 had an ARD of 4/27/19. The assessment was completed on 5/11/19 and was not submitted until 7/14/19. 5. Resident #5 had an ARD of 5/3/19. The assessment was completed on 5/17/19 and was not submitted until 7/14/19. 6. Resident #6 had an ARD of 5/25/19. The assessment was completed on 6/8/19 and was not submitted until 7/14/19. 7. Resident #9 had an ARD of 3/28/19. The assessment was completed on 4/11/19 and was not submitted until 7/14/19. 8. Resident #12 had an ARD of 4/22/19. The assessment was completed on 5/6/19 and was not submitted until 7/14/19. 9. Resident #13 had an ARD of 5/7/19. The assessment was completed on 5/21/19 and was not submitted until 7/14/19. 10. Resident #14 had an ARD of 4/29/19. The assessment was completed on 5/13/19 and was not submitted until 7/14/19. 11. Resident #15 had an ARD of 3/8/19. The assessment was not completed until 7/15/19 and was submitted on 7/15/19. 12. Resident #16 had a ARD of 5/1/19. The assessment was completed on 5/15/19 and was not submitted until 7/14/19. 13. Resident #17 had an ARD of 5/13/19. The assessment was completed on 5/27/19 and was not submitted until 7/14/19. 14. Resident #25 had an ARD of 6/5/19. The assessment was completed on 6/19/19 and was not submitted until 7/15/19. On 7/18/19 at 9:45 AM, the surveyor interviewed the MDS Coordinator. The MDS Coordinator stated that she was the only one that was responsible for the MDS Assessments and worked on a full-time basis. She further stated, that the Interdisciplinary Care Meetings and Care Plan meetings had been conducted timely, but that the assessments had not been submitted within the 14 days. The MDS Coordinator confirmed that there was a 14 day timeframe to have the assessment submitted and added that the above identified resident assessments were submitted late. N.J.A.C. 8:39 - 11.2

Based on observation, interview, and record review, it was determined that the facility failed to develop comprehensive care plans for 8 of 21 residents reviewed, Resident #21, #30, #35, #37, #40, #57, #59 and #60. This deficient practice was evidenced by the following: 1. On 7/15/19 at 9:07 AM, the surveyor observed resident #35 in bed awake. The surveyor then interviewed the resident, who stated that they went to [MEDICAL TREATMENT] and that their [MEDICAL TREATMENT] schedule was Tuesdays, Thursdays, and Saturdays. On 7/16/19 at 10:00 AM, the surveyor reviewed the resident's record which revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's initial Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 5/7/19, section O, indicated that the resident attended [MEDICAL TREATMENT] while a resident at the facility. The surveyor was unable to locate the resident's [MEDICAL TREATMENT] care plan. At that same time, the surveyor asked the Assistant Director of Nursing (ADON) for the resident's [MEDICAL TREATMENT] care plan. The ADON stated that there was no [MEDICAL TREATMENT] care plan but that there should have been. The ADON confirmed that the resident did attend [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays. 2. On 7/15/19 at 1:24 PM, the surveyor observed Resident #40 in a wheelchair in the resident's room. The skin on both lower extremities appeared shiny, tight and darker than the pigment of the skin. The residents legs appeared to be swollen. On 7/16/19 at 11:25 AM, the surveyor reviewed the resident's record. The current physician's orders [REDACTED]. There were doctor's progress notes dated 6/13/19 and 7/11/19 that revealed bilateral lower extremity [MEDICAL CONDITION] (Puffiness caused by excess fluid trapped in the body's tissues). The surveyor was unable to locate a care plan related to Resident #40's [MEDICAL CONDITION] in the resident's record. At 2:20 PM, the surveyor asked the ADON if she could locate the care plan for [MEDICAL CONDITION] in the resident's record. The DON stated that they could not locate a care plan for [MEDICAL CONDITION]. The surveyor then asked her if there should be one and the DON stated, Yes, especially because (the resident) is non-compliant with things we put into place. 3. On 7/15/19 at 9:29 AM, the surveyor interviewed Resident #59 in the resident's room. The resident was sitting on their bed when the surveyor noticed that the resident had long, jagged finger nails. The surveyor asked the resident if they would let the staff cut their nails if they asked. The resident said that they would let them. On 7/17/19 at 8:58 AM, the surveyor interviewed a Certified Nursing Assistant (CNA) that had been taking care of the resident for the past two weeks. The surveyor asked the CNA what care she did for the resident. The CNA stated, I wash (the resident) and dress (the resident). (The resident) can help to put on (the resident's) shoes but that's it. The surveyor asked about the resident's nails. The CNA stated, I clean them because (the resident) is always scratching and there is always stuff under them. The surveyor then asked the CNA if she noticed that they were long and jagged. The CNA responded, Yes, I notice that but I don't cut, nobody told me to cut them. We learned in school that not to cut because they might be diabetic and we might cut it too short. So I don't cut, just clean. The CNA said she noticed the scratches on his forehead and also legs from scratching. At 9:15 AM, the surveyor asked another CNA (CNA #2) who took care of Resident #59 in the past, about the kind of care she did for the resident. CNA #2 stated, I wash, I dress. The surveyor asked what she did for the resident's nails. She added,I sometimes clean the nails because (the resident) scratch (themselves) so I have to clean the nails. The surveyor asked if she cut them. CNA #2 responded, I never cut. I never saw them long. If I ever see them long I would tell the nurse. At 9:27 AM, the surveyor interviewed the Registered Nurse (RN), who was usually scheduled on the 3-11 PM shift, but stated, that she sometimes worked the 7-3 PM shift. The RN was asked about nail care. The surveyor asked who was responsible for cutting Resident #59's nails. The RN replied, The CNA's, it's part of the care of the resident. The surveyor then asked if the CNA's ever asked her to cut resident's nails. The RN stated, When it's difficult, Yes. The surveyor asked the RN specifically about Resident #59, and if the resident refused to have their nails cut. The RN stated, Yes, (the resident) has, (the resident) is very difficult. You have to approach (the resident) the right way. At 9:35 AM, the surveyor asked the ADON who was responsible for cutting the resident's fingernails. The ADON stated, Activities files them, the resident's nails are cut by the CNA's, usually the 3-11 PM CNA's, but if it's needed, the 7-3 PM will cut the nails. The surveyor asked the ADON specifically about Resident #59. She stated, (The residents) nails are probably long, but I know (the resident) is difficult at times, you have to know how to approach (the resident). The ADON further stated, The CNA's cut nails 3-11 PM every Wednesday. The resident scratches and if the CNA sees (the resident's) nails long, she should cut them. On 7/17/19 at 10:00 AM, the surveyor reviewed the residents record which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record included a care plan which was dated was 4/22/19 and read: Risk for impaired skin integrity r/t (related to) Immunologic deficit ,[MEDICAL CONDITION]., AEB (as evidenced by) [MEDICAL CONDITION] and skin irritations. Intervention number five read: Proper grooming, cut nails as needed. On 7/17/19 at 1:00 PM, the surveyor spoke with the Director of Nursing (DON) and discussed the concern regarding Resident #59's long nails and about the CNA's statements that they did not cut resident's nails. On 7/18/19 at 11:00 AM, the DON informed the surveyor that the CNA's (all shifts) were responsible for cutting the resident's nails. 4. On 7/15/19 at 1:14 PM, the surveyor observed Resident #37, ambulating from their room into the hallway . On 7/16/19 at 11:34 AM, the surveyor reviewed Resident #37's medical record which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor then reviewed the resident's Medication Administration Record [REDACTED]. On 7/16/19 at 11:47 AM, the surveyor reviewed the admission Minimum Data Set (MDS), an assessment tool, dated 6/6/19, which revealed under section N, Medications, that the resident received an antipsychotic and an anticoagulant seven of the last seven days. The surveyor then reviewed the Interdisciplinary Care Plans (ICP) for Resident #37 which did not include an ICP for [MEDICAL CONDITION] medication use or for anticoagulant medication use. On 7/16/19 at 1:14 PM, during surveyor interview, the ADON confirmed that there was no ICP for [MEDICAL CONDITION] medication use or for anticoagulant medication use for Resident #37. On 7/18/19 at 11:44 AM, during surveyor interview, the DON confirmed that there should have been an ICP for [MEDICAL CONDITION] medication use and for anticoagulant medication use. 5. On 7/15/19 at 1:09 PM, the surveyor observed Resident #57 sitting in a high back wheelchair, well groomed, with right sided facial drooping. On 7/16/19 at 8:34 AM, the surveyor reviewed the medical record of Resident #57 which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor then reviewed the significant change MDS dated [DATE], which revealed that the resident had a feeding tube. The MDS further revealed that the Care Area for Feeding Tube triggered as an area that required a decision for a new care plan, care plan revision, or continuation of a current care plan. At 12:50 PM, the surveyor reviewed the ICP's for Resident #57 which did not include an ICP for feeding tube care. On 7/18/19 at 11:44 AM, during surveyor interview, the DON confirmed that there should have been a ICP for feeding tube care. 6. On 7/14/19 at 10:45 AM, the surveyor observed Resident #60 in bed in their room. The head of the bed was elevated and the resident's body was covered with a blanket up to his/her chin. On 7/16/19 at 10:49 AM, the surveyor observed Resident #60 seated in a wheelchair at a table in the dayroom. Under the table, the resident's legs were on foot rests, the left foot had a sneaker, and the right foot had a soft, therapeutic shoe with hard bottom. The surveyor then reviewed Resident #60's medical record which revealed an Admission Record that indicated the resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor also reviewed the physician's orders [REDACTED]. The resident was prescribed a treatment of [REDACTED]. The resident also had an order dated 5/17/19, for [MEDICATION NAME] (a medication used to treat depression) 100 milligrams (mg) tablet by mouth daily for depression. Continued review of the medical record, revealed that there was no comprehensive care plan for Resident #60 related to the treatment of [REDACTED]. On the same day at 2:14 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM). The RN/UM stated that Resident #60 had a right heel DTI that was treated by cleaning the heel and applying [MEDICATION NAME] every shift. The RN/UM also stated that the resident was on [MEDICATION NAME] for depression. At that time, the surveyor along with the RN/UM, reviewed Resident #60's Care Plan's. The RN/UM acknowledged that there was no individualized care plan for the resident's skin and DTI, or [MEDICAL CONDITION] medication use. On 7/18/19 at 11:45 AM, the survey team met with the Administration and the Director of Nursing (DON). The DON also acknowledged there was no comprehensive individualized care plan in place to address the resident's skin and DTI or for [MEDICAL CONDITION] medication use and that one should have been in place. 7. On 7/16/19 at 10:42 AM, the surveyor observed Resident #30 in their room sitting in a wheelchair reading. The resident had a urinary collection hanging in a privacy bag from the left side of wheelchair below the seat. The surveyor then reviewed Resident #30's medical record which revealed an Admission Record that indicated that the resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed a physician's orders [REDACTED]. Further review of the medical record revealed that there was no individual comprehensive care plan for Resident #30 related to the use of a urinary catheter and the risk of developing a urinary tract infection. On 7/17/19 at 8:59 AM, the surveyor interviewed the RN/UM who stated the resident's nurse was responsible to provide Foley catheter care daily. The RN/UM stated the resident has had urinary tract infections [MEDICAL CONDITION] in the past. At that time, the UM and the surveyor reviewed the resident's care plan. The RN/UM acknowledged the resident did not have a care plan for the use or care of a urinary catheter, and potential risk of UTI, but they should have. On 7/18/19 at 11:45 AM, the survey team met with the Administration and the Director of Nursing (DON). The DON confirmed that there was no comprehensive individualized care plan in place to address the resident's use of a urinary catheter or the potential risk of developing a UTI and there should have been. 8. On 7/14/19 at 12:07 PM, the surveyor observed Resident #21 in the unit dayroom sitting in a wheelchair. The resident had a [MEDICAL CONDITION] (a surgically created hole in the windpipe that provides an alternate airway for breathing) in their neck that was secured with a [MEDICAL CONDITION] tie. The [MEDICAL CONDITION] was uncapped. The surveyor did not observe a splint on the left hand of the resident. On 7/15/19 at 11:00 AM, the surveyor observed Resident #21 in bed with the head of bed elevated. There was an air mattress on the bed and the resident was wearing a hospital gown. The resident had an uncapped [MEDICAL CONDITION] that was open to room air. There was a towel on the residents chest under the [MEDICAL CONDITION]. The surveyor did not observe a splint on the residents left wrist. On 7/17/19 at 8:06 AM, the surveyor observed Resident #21 in bed with the head of the bed elevated. There was a pillow under the right side of the resident and humidified oxygen was being administered via a [MEDICAL CONDITION] collar. The resident had their eyes open and appeared to follow the surveyor around the bed. The surveyor did not observe a splint on the left hand of Resident #21. At 9:02 AM, the surveyor reviewed the physician's orders [REDACTED]. The TAR documented the that the splint had been applied on the same days the surveyor observed that it was not in place. The TAR was circled with respect to the speaking valve which identified that the device wasn't utilized. The surveyor then reviewed Resident #21's care plans that identified a care plan for the problem: Risk for injury r/t immobility due to medical condition. (The Resident) requires total care with most of his ADL's (Activities of Daily Living). Under interventions it read: Provide daily passive exercises of upper/lower extremities to prevent contractures. The care plan did not include the placement of the left hand splint. The care plan with the identified problem: Impaired verbal communication r/t [MEDICAL CONDITION] did not include a current or discontinued intervention of the use of the speaking valve. On 7/18/19 at 8:55 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed that she was aware that there were issues with the Care Plans. At 3:00 PM, the surveyor reviewed the facility's policy and procedure titled, Nursing Care Plan, dated 12/2018 which read: under Policy: Individualized patient care plan will be developed within 72 hours of admission. Care plan provides guidelines for initiating, customizing, and following a goal directed plan of care based on best practice. Continued under Procedures: 1. Staff will assess resident upon admission. 2. Evaluate resident's condition and developed a care plan in accordance to the needs to the resident, with stated goals, identify priority problems, interventions and expected outcomes. 3. For each priority problem, develop a set goal, evaluate and document if goals were met. 5. Problems that are resolved should be highlighted and marks as completed/achieved/resolved. N.J.A.C. 8:39-11.2(1)

Based on observation, interviews, review of the medical records and other pertinent facility documents, it was determined that the facility failed to ensure that treatments were administered according to physician orders [REDACTED].#21 and #40) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 7/14/19 at 12:07 PM, the surveyor observed Resident #21 sitting in a wheelchair in the unit dayroom during an activity. The resident had their eyes open and their head was resting on the headrest and leaning toward their left. There was a Hoyer pad (a pad used for a mechanical lift transfer) under neath the resident and they had a [MEDICAL CONDITION] (a surgical opening in the neck) and a towel on their chest. Resident #21 was dressed and groomed and had their feet on the wheelchair (WC) footrests and upper extremities were at their side. The surveyor did not observe a speaking valve on the tracheotomy or a splint on Resident #21's left hand/wrist. At 12:20 PM, the surveyor observed Resident #21 was propelled by staff down the unit hallway. On 7/15/19 at 11:00 AM, the surveyor observed Resident #21 in bed with the head of the bed elevated. There was an air mattress on the bed and the resident's [MEDICAL CONDITION] was open to room air. There was a towel on their chest under the [MEDICAL CONDITION]. The surveyor did not observe a speaking valve on the [MEDICAL CONDITION] nor did they observe a splint on Resident #21's left hand/wrist. On 7/17/19 at 8:06 AM, the surveyor observed Resident #21 in bed with the head of the bed elevated. There was a pillow under the residents right side. Oxygen was being administered via a [MEDICAL CONDITION] collar. The tube feeding was infusing through a gastrostomy site from a bag that was hanging on a pole next to the bed. There was no speaking valve on the [MEDICAL CONDITION], nor was the splint on the residents left hand/wrist. At 9:02 AM, the surveyor reviewed Resident #21's face sheet which revealed that on 9/21/09, the resident was admitted to the facility and a re-admission date of [DATE]. Resident #21 had [DIAGNOSES REDACTED]. The surveyor then reviewed the current physician's orders [REDACTED]. Place speaking valve on [MEDICAL CONDITION] at 9 AM and remove at bedtime as tolerated under nursing supervision. There was also an order [REDACTED]. Apply left hand splint 2 - 3 hours in the morning (on at 10 am and off at 1 pm) and 2-3 hours in the evening (on at 4 pm and off at 7 pm) or as tolerated. The surveyor then reviewed Resident #21's current and active Care Plan's (CP). There was no CP or intervention related to the use of a speaking valve or for the left hand splint. At 10:25 AM, the surveyor observed a Registered Nurse (RN) administer medications through Resident #21's gastrostomy tube ( a tube inserted through the abdomen that delivers nutrition directly to the stomach). The resident was in a WC at their bedside. The resident did not have a speaking valve in place, nor did the resident have the splint on their left hand. When the surveyor inquired about the speaking valve and the splint, the RN stated that she was not aware of a speaking valve or the use of the left hand splint. At 1:15 PM, the surveyor observed an RN and two Certified Nursing Assistants (CNA's) transfer Resident #21 back to bed. The surveyor did not observe a hand splint on the left hand of the resident. Once the resident was securely in bed, the surveyor interviewed the CNA who stated that she was the restorative aide providing care while the primary restorative aide was on vacation. The Restorative CNA confirmed that she was responsible for placing the splint on Resident #21, and that the left hand splint had not been applied to the resident's left hand today and, that it was on the shelf next to the resident's bed. The CNA further stated, that the splint goes on in the morning or the afternoon. At 3:25 PM, the surveyor reviewed the Treatment Administration Record (TAR) for 7/2019. The current TAR revealed documented initials for the month of (MONTH) 2019 that the left hand splint was in place on the resident during the day (7 - 3) shift as well as the evening (3 - 11) shift. The current TAR for the use of the speaking valve revealed 28 boxes initialed and circled (not used). There was one undated, un-timed note on the back of the TAR that read: Not tolerating speaking valve x 3. On the same day at 3:30 PM, the surveyor interviewed the RN about the left hand splint and the speaking valve. The RN stated that the nurse was responsible for initialing the TAR when a treatment had been performed or had been observed to be in use for the resident. The Assistant Director of Nursing (ADON) added at that time, that if there was an initial with a circle around it, that indicated that the treatment was refused by the resident or did not occur and the reason would be identified on the back of the TAR. The RN and ADON could not explain why the speaking valve remained on the current TAR if the resident was not tolerating it. The surveyor was unable to locate any other documentation that the speaking valve was not being tolerated by Resident #21. The surveyor then asked the RN about the hand splint. The RN stated that the initials on the TAR indicated that the treatment had been carried out. The RN could not explain the multiple observations made by the surveyor of Resident #21 not wearing the hand splint. At 3:35 PM, the surveyor observed Resident #21 in bed with the head of the bed elevated. Oxygen was observed being administered via the [MEDICAL CONDITION] collar. There wasn't a speaking valve in place in the residents [MEDICAL CONDITION] and the resident's hands were covered with a blanket. At that time, the RN walked into the resident's room and lifted the sheet off the residents left arm to reveal that the hand splint was in place. On 7/18/19 at 8:35 AM, the surveyor interviewed an Occupational Therapist (OT) who stated that Resident #21 had the left hand splint to prevent a contracture in the resident's left hand and that the resident was to wear it daily, as tolerated. The surveyor then reviewed the OT Discharge Summary for the period of 10/29/16 - 11/23/16, which read under Long Term Goal #3.0: Patient will safely wear resting hand splint and hand cone for up to six hours with minimal s/s (signs and symptoms) of redness, swelling, discomfort or pain. At 8:55 AM, the surveyor interviewed the Director of Nursing (DON) who revealed that there wasn't a speaking valve at Resident #21's bedside but the she had an extra speaking valve if it was needed. The DON could not explain why the TAR was being signed if the treatment did not take place or if the treatment was no longer appropriate. At 1:00 PM, the surveyor interviewed the Respiratory Therapist (RT). The RT stated that he had completed an evaluation of Resident #21 and that the resident was not a good candidate for a speaking valve. The RT added that it was an old order and that he had observed Resident #21 monthly for the past 6-8 months, and that he had not observed the speaking valve in place. The RT informed the surveyor that today he had made the recommendation to the physician that the order for the speaking valve be discontinued. 2. On 7/15/19 at 1:24 PM, the surveyor observed Resident #40 in a WC in the resident's room. The skin on both lower extremities appeared shiny, tight and darker than the pigment of the skin. The lower extremities appeared to be swollen. On 7/16/19 at 11:25 AM, the surveyor reviewed the resident's record. The current POS had an order dated 7/9/19, that read: Keep bilateral legs elevated as much as possible. There were doctor's progress notes dated 6/13/19 and 7/11/19 that noted Resident #40 had bilateral lower extremity [MEDICAL CONDITION] (swelling caused by excess fluid trapped in the body's tissues). The surveyor then reviewed a telephone order dated 4/9/19, which read: Wrap L (left) Lower leg with Unna Boot (compression dressing) change Q (every) four (4) days. A second telephone order dated 4/19/19 read: Wrap R (right) Lower leg with Unna Boot Q 4 days in a.m. The aforementioned orders were not on the (MONTH) 2019, (MONTH) 2019, or (MONTH) 2019 POS's. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 included the order which was done as indicated by the nurse's signed initials every four days. The (MONTH) 2019 and the (MONTH) 2019 TAR's did not include the order for the Unna boot application. On 7/16/19 at 11:40 AM, the surveyor asked the ADON about the Unna Boot order that was not carried over after (MONTH) 2019. The ADON stated that, It's a chronic thing, it never really has gone away, sometimes it's worse, sometimes it's better. It's on and off related to the resident's [MEDICAL CONDITION] of the bilateral lower extremities. On 7/17/19 at 1:00 PM, the surveyor asked the Director of Nursing (DON) about the physician's orders [REDACTED]. On 7/18/19 at 11:44 AM, the DON replied to the surveyor inquiry about the Unna Boot. The DON stated, The Unna boot order dated 4/9/19 was clarified that night. I can't determine if the POS was faxed or not. The pharmacy did not pick it up. During recap (the nurse writing of the new TAR for the new month) it was not picked up. The first one in April, it was on the TAR, but after (MONTH) it was not transcribed. N.J.A.C. 8:39-27.1 (a)

Based on interview, review of the medical record and review of other facility documentation, it was determined that the attending physician failed to document a discharge summary which included a recapitulation (recap) of the resident's stay and a final summary of the resident's status for 1 of 2 closed record's reviewed for discharge (Resident #65). This deficient practice was evidenced by the following: On 7/18/19 at 9:40 AM, the surveyor reviewed the closed medical record for Resident #65. The closed records revealed that the resident was admitted to the facility on [DATE], and was discharged home on[DATE]. Further review of the medical record revealed that there was no documented physician discharge summary. At 10:40 AM, during surveyor interview, the Director of Nursing (DON) stated that the physician does not document a recap of the resident's stay. At 11:55 AM, the DON confirmed that Resident #65's medical record did not contain a discharge summary. Later that day at 1:15 PM, during a follow-up interview, the DON stated that the facility did not have a policy regarding discharge summary. N.J.A.C. 8:39-35.2(d)(16)

Based on observation, interview, medical record and review of other facility documentation, it was determined the facility failed to 1.) ensure the required Federal narcotic acquisition forms (DEA 222 form) were dated and signed by the Medical Director as of the day it was submitted for filling for 4 of 4 forms provided; and, 2.) accurately reconcile and account for controlled medications for 1 of 4 medication carts reviewed. This deficient practice was evidenced by the following: 1. On 7/18/19 at 11:32 AM, the surveyor requested from the Director of Nursing (DON) to review the facility's controlled substance ordering form DEA 222 blank forms and receipts. At that time, the DON handed a binder that contained both blank DEA 222 forms and receipts of the DEA 222 forms. The surveyor observed that the blank forms in an envelope contained four DEA 222 forms that had not been filled out but were already signed by the Medical Director, Form # 0643, # 0646, # 0648 and # 0650. On 7/18/19 at 12:21 PM, during surveyor interview, the DON confirmed that the DEA 222 forms should not have been pre-signed by the Medical Director. On 7/18/19 at 1:15 PM, during surveyor interview, the DON stated that the facility did not have a policy related to the DEA 222 forms. 2. On 7/18/19 at 1:25 PM, the surveyor, along with the licensed practical nurse (LPN), inspected the second floor, low side medication cart. Inspection of the narcotic medication lock box revealed a resident specific, partially completed medication dispensing card. The declining inventory sheet attached to the medication dispensing card revealed four of the original 50 pills had been dispensed. When the surveyor inquired as to why the medication was in the lock box and not in the narcotic inventory, the LPN Unit Manager (LPN/UM) stated the medication was removed from inventory because the resident was discharged about one week ago. The LPN/UM stated the process was once a resident was discharged the medication was given to the Director of Nursing (DON) for disposal. The LPN/UM further stated that the nurse on the cart was responsible for the transfer of the medication to the DON. The LPN/UM acknowledged that the medication should have been removed from the medication cart and given to the DON for disposal. On 7/18/19 at 1:50 PM, the DON informed the surveyor that the process was once a resident was discharged , all discontinued medication, including narcotics, should be brought to her office. The DON further stated, that the day after a resident was discharged or a medication was discontinued, she would follow up with the nurse to ensure all medications were removed from the nursing unit. The DON confirmed the floor nurse missed bringing down the medication and she, the DON, had missed it as well. The DON further acknowledged she was not aware the medication remained in the medication cart on the nursing unit until the surveyor brought it to her attention. On 7/18/19 at 2:03 PM, DON informed the surveyor that there was no policy regarding the narcotic inventory process, and that there was a verbal process only. N.J.A.C. 8:39-29.7(c)

Based on observation, interview, review of the medical record and of other facility documentation, it was determined that the facility failed to 1). document the correct dosage of the [MEDICAL CONDITION] medication on the behavior/intervention monthly flow record; and, 2). adequately monitor target behavior for the use of [MEDICAL CONDITION] medications. This was identified for 2 of 6 residents (Resident #9 and #63) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 7/16/19 at 9:01 AM, the surveyor observed Resident #63 ambulating in the unit hallway. At 9:05 AM, the surveyor reviewed the resident's medical record which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED]. The surveyor then reviewed the Behavior/Intervention Monthly Flow Record (BIMFR) for (MONTH) 2019, which was in the Medication Administration binder, which revealed [MEDICATION NAME] two (2) mgs by mouth one (1) tab two times (2 X) daily. On 7/18/19 at 10:00 AM, the surveyor reviewed the previous three months of BIMFRs, that were in the resident's chart, which revealed the following: three pages of the BIMFR documenting [MEDICATION NAME] 2 mg by mouth 1 tab 2 X daily that were undated, two pages of the BIMFR that were dated 5/19 with the medication [MEDICATION NAME] 3 mg by mouth daily documented on one of the pages and blank on the other page and three pages of the BIMFR that were dated 4/19 with [MEDICATION NAME] 3 mg by mouth 1 tab daily. At 11:53 AM, during surveyor interview, the Director of Nursing (DON) confirmed that the (MONTH) 2019 BIMFR had the wrong dosage of [MEDICATION NAME] documented. The DON further confirmed that the BIMFR should always have the correct medication, correct dosage and correct behaviors to monitor for the resident. 2. On 7/14/19 at 11:47 AM, the surveyor observed Resident #9 in bed, wearing a hospital gown. The resident stated that they were not feeling well. The resident appeared to have tongue thrusting when speaking. The resident stated that they get depressed sometimes and take a medication for that every day. The resident further stated that he/she felt less depressed when they take the medication. On 7/16/19 at 10:50 AM, the surveyor reviewed the resident's medical record which revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor then reviewed the Physician order [REDACTED]. [MEDICATION NAME] 1 milligram (mg) every 12 hours for anxiety. [MEDICATION NAME] 15 mg three times a day for anxiety. [MEDICATION NAME] 50 mg three times a day for depression. Pimozide 2 mg daily at 9:00 AM, 2:00 PM, 6:00 PM, and 9:00 PM for [MEDICAL CONDITION] disorder. Quetiapine 50 mg three tabs (150 mg) daily at 9:00 PM daily for [MEDICAL CONDITION] disorder. The surveyor then reviewed the BIMFR for (MONTH) 2019, which was in the Medication Administration binder. The BIMFR revealed monitoring of [MEDICATION NAME], quetiapine, and [MEDICATION NAME], however no monitoring for behaviors related to the use of [MEDICATION NAME], or pimozide. The behaviors that were monitored for [MEDICATION NAME], quetiapine and [MEDICATION NAME] were not differentiated by medication they included, episodes of panic attack and shaking and afraid to stand, as well as felt eyes moving up and down. Review of (MONTH) 2019 BIMFR revealed only quetiapine and [MEDICATION NAME] were monitored, however there were no targeted behaviors identified for either medication use. (MONTH) 2019 could not be reviewed because it could not be located by either surveyor or staff. On 7/17/19 at 9:20 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM). The RN/UM stated that Resident #9 was alert and oriented, had anxiety and [MEDICAL CONDITION] and was being treated with quetiapine, [MEDICATION NAME] and [MEDICATION NAME]. The RN/UM stated the resident had a recent gradual dose reduction of [MEDICATION NAME]. At that time, the RN/UM stated the resident's behaviors were monitored and kept with the Medication Administration Record [REDACTED] The surveyor then reviewed the Consultant Pharmacist's Monthly Report dated 5/30/19, which revealed the pharmacist comment regarding Resident #9 read: This resident's psychoactive summaries are not up-to-date or it is not noted in chart. Please ensure this is updated. On 7/18/19 at 12:57 PM, the DON stated that she was unable to locate any other behavior monitoring forms other than the ones provided, (MONTH) 2019 and (MONTH) 2019. The DON further acknowledged that all of the resident's [MEDICAL CONDITION] medications should have been monitored monthly and that each medication should have its own specific behavior to be monitored. At 3:10 PM, the surveyor reviewed the facility's policy and procedure titled, [MEDICAL CONDITION] Medications, dated (MONTH) 2019, which read: under Policy: Residents on [MEDICAL CONDITION] medications will have appropriate diagnosis; ensure for appropriate use, will be evaluated by Psychiatrist and will have behavior monitoring in place, identifying target behaviors. under Procedures it read: 1. (The Facility) will comply with state and federal regulations related to the use of [MEDICAL CONDITION] medications to include the regular review for continued needs, appropriate dosage, side effects, risks or benefits. 2. Staff will do assessment to determine the reasons why resident is on [MEDICAL CONDITION]'s medications and identify target behaviors. 3. Behavior sheets will be started on admission. 4. Monitors [MEDICAL CONDITION] use daily charting any adverse reactions to the medications. 5. Nursing will monitor the presence of target behaviors daily, every shift. 8. [MEDICAL CONDITION] medications include anti-anxiety/hypnotic, antipsychotic and antidepressant. On the same day at 3:15 PM, the surveyor reviewed the undated facility's policy and procedure titled, Policy Behavior Monitoring Regimen, which read: under Policy: Residents who are on [MEDICAL CONDITION] medications will be placed on Behavior Monitoring regimen. under Procedures it read: 2. List the target behaviors on the behavioral management intervention sheets. 3. Staff will write #1 (one) (each shift daily) in the column, if target behavior (s) is/are observed. 4. Staff will write #0 (zero) (each shift daily) in the column, if target behavior (s) is/are not observed. 8. Consistent Zeroes indicating that NO TARGET BEHAVIORS were manifested/observed; reassessment is required, why is the resident still on the [MEDICAL CONDITION] medication or still at the same dosage. N.J.A.C. 8:39-27.1 (a)

Based on interview and record review, it was determined that the facility failed to assure that the Medical Director, or designee, attended the quarterly Quality Assurance (QA) meetings. This was identified for 2 of 3 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: On 7/18/19 at 12:00 PM, the surveyor interviewed the Director of Nursing (DON) and asked for the sign in sheets for the last three QA meetings. When the surveyor reviewed the sign in sheets for the meetings, it was noted that the Medical Director had not been in attendance for two of the three meetings. The third quarter of (YEAR) sign in sheet was dated (MONTH) (YEAR), the fourth quarter sign in sheet was dated (MONTH) 2019, and the first quarter of 2019 was dated 4/30/19. There was no signature on the third or fourth quarter meetings to indicate that the Medical Director attended those meetings. According to the sign in sheets, the Medical Director attended the QA meeting on 4/30/19 but not the two previous meetings. The surveyor asked the DON to provide the sign in sheet for the meeting prior to (MONTH) (YEAR). The DON stated that she couldn't find it. On 7/18/19 at 12:30 PM, the surveyor reviewed the facility's policy and procedure for their QAPI (Quality Assurance, Performance Improvement) Program which had an approved date of 11/23/17, and a revised date of 5/5/19. Under Governance and Leadership it read: QAPI program is provided through a committee structure that is accountable to (The Facility) Executive Leadership. (The Facility) Board of Directors fully delegates responsibility for oversight of the QAPI program to the QAPI Steering Committee. The QAPI Steering Committee is responsible for providing quarterly report on the QI program to (The Facility) Board of Directors at it's quarterly meeting. (The Facility) Leadership Team and QAPI Steering Committee have the responsibility for planning, designing, implementing, and coordinating consumer care and service and selecting QAPI activities to meet the needs of residents and families. The QAPI plan that was provided to the survey team did not list the members of the committee. N.J.A.C. 8:39-33.1 (b)

Based on observation and interview, it was determined that the facility failed to implement infection control practices that would decrease the possibility of the spread of infection. This was identified for Resident #22, 1 of 4 residents observed during treatments. This deficient practice was evidenced by the following: On 7/17/19 at 10:27 AM, the surveyor observed the Assistant Director of Nursing (ADON) perform a wound treatment to the buttock wound of Resident #22. The ADON cleaned the overbed table with a Clorox wipe then washed her hands. When the table was dry, she placed a plastic bag over it and then set up a clean field on the plastic bag. She placed medi honey (a wound care dressing paste), an individually wrapped gauze, individually wrapped cotton tipped swabs, wound cleanser, and scissors on the clean field. The ADON then washed her hands, and she repositioned the resident with the help of a Registered Nurse (RN). The ADON washed her hands, then gloved and cleaned the wound with wound cleanser and removed old packing and then patted the wound dry. The ADON then applied the medi honey with a cotton tipped swab and then packed the wound with a small strip of calcium alginate (a highly absorbent dressing) and covered it with a border gauze. The ADON then washed her hands and discarded the open items from the overbed table and cleaned the table and scissors with a Clorox wipe. The surveyor then observed the ADON drop a sealed package of the border gauze dressing on the floor and then picked it up and placed it with the extra, unused individually wrapped gauze pads in the original box. The surveyor asked the ADON what it was that she dropped on the floor. She stated, An extra border gauze. The ADON took the border gauze that had fallen on the floor, the unused individually wrapped gauze, and unused individually wrapped cotton tipped swabs and carried them to the treatment cart down the hall. The ADON placed the items on top of the treatment cart and opened the drawer. The surveyor then informed the ADON of the observation made during the treatment regarding the package of border gauze that was on the floor that had been returned to the box for general use. The ADON stated, It was wrapped so isn't that ok? Because it was closed? At 1:00 PM, the surveyor spoke with the DON, who also indicated that she was the facility's Infection Preventionist, along with the ADON, about the wound treatment observation. The DON was notified that the ADON dropped the border gauze on the floor and was going to return it to the treatment cart for general use when she was stopped by the surveyor. On 7/18/19 at 11:44 AM, the DON responded to the concern presented on 7/17/19 regarding the ADON dropping the border gauze on the floor and returning it to the treatment cart. The DON stated, Infection control, anything on the floor is considered contaminated and has to be discarded. N.J.A.C. 8:39 19.4 (a)

Based on interview and review of the medical record, and of other facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the transfer to the hospital for 3 of 3 residents reviewed for hospitalization s (Resident #23, #38 and #60). This deficient practice was evidenced by the following: 1. On 07/18/19 at 11:00 AM, the surveyor reviewed Resident #60's medical record. The medical record revealed that the resident was transferred to the hospital on [DATE], and was readmitted to the facility on [DATE]. The resident was again transferred to the hospital on [DATE], and readmitted to facility on 5/16/19. The surveyor did not observe evidence of the written notification of the transfers. 2. On 7/18/19 at 8:00 AM, the surveyor reviewed Resident #38's medical record. The record revealed that the resident was hosptalized on [DATE] for Pneumonia, Severe Gastro-Intestinal Bleed, [MEDICAL CONDITION] and remained in the hospital at the time the record was reviewed. On 7/18/19 at 8:57 AM, the surveyor asked the Director of Nursing (DON) if the facility had evidence that the resident and/or resident's representative, received written notification that the resident was transferred to the hospital. The DON said the resident or resident's representative were not provided with written notification that the resident was transferred to the hospital. The DON stated, I have to be honest, we're not doing that. 3. On 7/17/19 at 3:19 PM, the surveyor reviewed the New Jersey Universal Transfer Form (NJUTF) which revealed that Resident #23 had been transferred from the nursing facility to the hospital emergency roiagnom on [DATE], for an acute [MEDICAL CONDITION] (a bone in the upper arm). There was no evidence that the resident or resident representative was given written notification of the transfer. On 7/18/19 at 11:47 AM, the DON confirmed that there was no written notification provided to Resident #23's representative or to the Office of the Ombudsman. At 11:50 AM, during surveyor interview, the Director of Nursing stated that the facility does not give written notification of the transfer to the hospital to the resident and/or the resident's representative. At 12:40 PM, the surveyor reviewed the facility's policy and procedure titled, Transfer Agreement, dated 6/28/19, which read: Number 7: The patient or, if indicated, the patient's relatives or persons or agencies responsible for the patient shall be given adequate notice of the nature of the intended transfer by the institution transferring the patient prior to the transfer. N.J.A.C. 8:39-5.3 (b)

Based on interview, review of the medical record and other facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy prior to transfer to the hospital for 3 of 3 resident's (Resident #23, #38, and #60) reviewed for hospitalization s. This deficient practice was evidenced by the following: 1. On 07/18/19 at 11:00 AM, the surveyor reviewed Resident #60's medical record which revealed, that the resident was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. The resident was again transferred to the hospital on [DATE] and readmitted to facility on 5/16/19. The surveyor did not observe evidence of written notification of the facility's bed hold policy prior to transfer. 2. On 7/18/19 at 8:00 AM, the surveyor reviewed Resident #38's medical record. The record revealed that the resident was hosptalized on [DATE] with [DIAGNOSES REDACTED]. At the time the record was reviewed, the resident remained in the hospital. 3. On 7/17/19 at 3:19 PM, the surveyor reviewed the New Jersey Universal Transfer Form (NJUTF) which revealed that Resident #23 had been transferred to the hospital on [DATE]. The surveyor did not observe evidence of written notification of the facility's bed hold policy prior to the transfer to the hospital. On 7/18/19 At 8:57 AM, the surveyor asked the Director of Nursing (DON) if the facility provided written information to the resident or resident's representative about the facility's bed hold policy. The DON stated, No, we do not do that. We give it on admission but not when the resident is transferred to the hospital. At 11:47 AM, the DON stated that the bed hold and transfer written notification was not in place. The DON then confirmed that written notification was not provided to Resident #23's representative. At 11:50 AM, during surveyor interview, the DON stated that the facility does not give written notification of the transfer to the hospital to the resident and/or resident's representative. At 12:40 PM, the surveyor reviewed the facility's undated policy and procedure titled, Bed Hold Policy, which did not contain information regarding written notification of the facility's bed hold policy. N.J.A.C. 8:39-5.1 (a)

Complaint #NJ 388 Based on observation, interview and record review, it was determined that the facility failed to provide supervision of a staff member who had received disciplinary action for allegations of verbal abuse to residents. The staff member's behavior escalated to a physical altercation with a resident, which resulted in physical pain and psychological trauma to the resident. This deficient practice was identified for 1 of 15 sampled residents, Resident #12, as evidenced by the following: The surveyor reviewed the medical record of Resident #12, who had [DIAGNOSES REDACTED]. The surveyor observed the resident on 3/17/11 at 11:00 a.m., in a large group activity, seated in a high back wheelchair. The resident was observed to speak only Spanish. The surveyor reviewed Resident #12's medical record on 3/17/11. A nurses' note dated 2/23/11 revealed the following notation: "Approached resident again and asked of what had happened Sunday 2/20/11. Resident told the incident again consistent with demonstration. Resident is calm and cooperative." Review of documentation provided by the facility regarding the 2/20/11 incident revealed an investigation which stated "Resident complained of physical abuse, CNA (#1)hit him on the back of his head 3 times, pinched his arm and hit his face while he was in the bathroom. " Review of an " Employee Statement Form " dated 2/20/11, revealed the following: " When I opened the door to the restroom, I saw Resident and CNA pushing each other. Resident had his fists closed appearing as if he wants to punch CNA. CNA had her hands on top of Resident's closed fists, pushing back. Resident appeared extremely agitated and angry. I assisted CNA to finish cleaning him up and Resident was put to TV room. At the TV room, I requested another CNA to translate what Resident was yelling about. As he continued to yell the translating CNA stated the resident was saying that he was hit by CNA in head and the side of his face and pinched on the arm." This statement was signed by the unit manager. On 3/17/11 the surveyor reviewed the employee file of the CNA who was involved in the incident, which revealed that on 5/20/10, 8/2/10 and 2/4/11, the CNA received disciplinary action for verbal abuse to residents. On 3/21/11 at 10:30 a.m., the surveyor interviewed the unit manager regarding the incident. The unit manager repeated all of the information that was in the above written statement. The unit manager told the surveyor that the resident was very upset after the incident and repeatedly pointed to the CNA and said "mal," which means "bad" in Spanish. The unit manager stated that the resident repeated the same story when interviewed several days after the incident. The unit manager also stated that she was not aware that the CNA who was involved in the incident had been accused of verbal abuse to residents, on three occasions prior to this incident. The unit manager told the surveyor that she was not aware that the CNA required monitoring and supervision as a result of the incidents. On 3/21/11 at 11:00 a.m., the Director of Nurses (DON) provided the surveyor with sign in sheets from recent abuse prevention programs in the facility. The name of the CNA who was involved in the 2/20/11 incident did not appear on any of the sign in sheets. Further review of the employee file of the CNA revealed that the CNA was terminated after the incident was investigated. NJAC 8:39- 4.1(a)(6)