Every finding on record at Excel Care at Egg Harbor

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) prepare food in a manner to prevent food-borne illness, b.) maintain the kitchen equipment in a sanitary manner, c.)maintain food-contact equipment in a sanitary condition in 2 of 2 Nourishment Rooms (1st Floor and 2nd Floor), and d.) label and date resident's food in 1 of 2 Nourishment rooms (2nd Floor Nourishment room).This deficient practice was evidenced by the following:On 6/8/2026 at 9:50 AM, the surveyor, accompanied by the Food Service Director (FSD) toured the kitchen, and the following was observed:The surveyor observed the FSD open the ice machine door. Black residue was noted on the proximal end of the white plastic located inside the machine. At that time, the surveyor interviewed the FSD who stated that the ice machines were checked weekly by the kitchen staff and monthly by the maintenance department. The FSD director confirmed that the ice machine needed to be cleaned.In the Snack refrigerator, there was a 4-pound (lb.) partially used jar of grape jelly received on 6/1/26, which was not labeled with the use-by date. At that time, the surveyor interviewed the FSD who stated that there should be a use-by date on all opened food items.The Walk-In refrigerator had a 1.5 lb package of partially used Swiss cheese. The cheese was not labeled with the received, opened, and use-by date. At that time, the FSD confirmed the finding.On 6/9/2026 at 12:41 PM, the surveyor, accompanied by Registered Nurse/Unit Manager (RN/UM) toured the 1st floor Nourishment Room. The ice machine was noted with tape on the exterior of the middle right-hand corner near the dispenser. It was further noted that the dispenser contained black residue on multiple areas of the interior and exterior parts of the dispenser. The drip tray also contained white residue throughout. At that time, the surveyor interviewed the RN/UM who stated that the ice machine was not being used since 6/8/2026 at the end of her shift due to infection control issues with the tape. There was no signage posted on the ice machine to indicate that it was out of use. The RN/UM stated that she should have put a sign on the ice machine so other staff members would know not to use it.On 6/9/2026 at 12:59 PM, the surveyor interviewed Certified Nursing Assistant (CNA #2) who stated that around 7:00 AM, he checked on his residents, then got them ice from the ice machine in the same Nourishment Room.On 6/09/2026 at 1:03 PM, the surveyor, accompanied by the Licensed Nursing Home Administrator (LNHA) returned to the first floor Nourishment Room. He stated that the internal part of the ice machine was cleaned by a vendor every six months, and the next cleaning was due in July. He added that housekeeping cleaned the outside of the machine daily. He confirmed that the ice machine needed to be cleaned.On 6/9/2026 at 1:17 PM, the surveyor, accompanied by Licensed Practical Nurse (LPN#1), toured the second-floor Nourishment Room and observed the following:The Ice machine contained a large amount of black and brown residue on the interior and exterior of the dispenser.The tubing used to dispense the water was noted to be light green throughout.The drip tray contained white residue throughout.The refrigerator contained a clear plastic bowl with a red lid that contained chicken, peppers, and gravy, and an empanada wrapped in aluminum foil. LPN/UM #1 stated that she did not know who the food items belonged to. She further stated that all resident food should be labeled with their name, room number, and a discard date at the time that it was placed in the refrigerator.On 6/10/2026 at 9:07 AM, the surveyor interviewed the housekeeper (HK), who stated that she cleaned the ice machine every day. She added that she applied the spray to clean the exterior and uses a brush to clean the interior parts. She further stated that it should be clean at all times because the residents drink water from it.On 6/10/2026 at 9:16 AM, the surveyor interviewed the Housekeeping Director (HD) who stated that the ice machines were disinfected daily. He added that they used disinfectant spray and wiped down the outside of the machine, including the drip tray. He further stated there was a special brush that goes up in the tubing that dispenses the water, and where the ice comes from. He further stated that it was done every 2-3 days or as needed. He added that the maintenance would have to remove the clear hard plastic dispenser so it could be cleaned because it can not be properly cleaned unless it was removed. He added that maybe the facility needed to get a specialized company to come in and do it. On 6/10/2026 at 9:48 AM, the surveyor interviewed the Maintenance Director (MD) who stated the maintenance department checked the ice machines quarterly. He added that the facility has been using an outside on-call vendor over the last 3 years, but the facility primarily maintained it in-house. He further stated that they used brushes to clean all the ports where the water was dispensed. He explained that they used skinny brushes to get inside the tubing. He added that quarterly they take the dispenser (clear round piece) off and cleaned it. He further stated that the facility escalated it to be cleaned more frequently because when he took it off to do the cleaning, he realized they had heavy iron in this area, and the iron caused it to corrode. He noted that he called to get the placement part for the 1st floor ice machine that was broken. On 6/10/2026 at 10:17 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that the ice machine should be cleaned daily. The surveyor showed the IP a picture of the second-floor ice dispenser ( the hard plastic part) that was taken on 6/9/2026 during the tour. She shockingly stated, Oh my Gosh! The IP added that she did not know where the green color in the water dispensing tube was coming from. She further stated that for infection control purposes, the ice machine should be maintained much better. On 6/11/2026 at 9:21 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the ice machine should be maintained in a clean manner. She also stated that the nursing staff should report it to maintenance if the ice machine was not clean, and then they should ensure that ice and water was provided from another source. She further stated that the resident's food should be labeled with their name, room number, a received and discard date at the time the food was received.A review of the facility's undated Ice Machines and Ice Storage Chests policy included, Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice.A review of the facility's Food Receiving and Storage policy, reviewed August 2025 included All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).All food belonging to residents are labeled with the resident's name, the item and the use by date. NJAC 8:39-17.2 (g); 19.4

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident who was previously identified with decreased range of motion and mobility consistently received prescribed treatments for contractures (shortening and hardening of muscles, tendons, often leading to deformity and rigidity of joints) in accordance with professional standards of practice and physician's orders.This deficient practice was identified for 1 of 2 residents (Resident #50) reviewed for positioning and mobility and was evidenced by the following:On 6/8/2026 at 10:00 AM during the initial tour of the facility, Surveyor #1 observed Resident #50 resting in bed. When interviewed, the resident stated that they could not walk and were not receiving therapy services.On 6/9/2026 at 11:55 AM, the surveyor reviewed Resident #50's electronic medical record (EMR) which revealed the following:A review of the resident's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: cognitive communication deficit, schizoaffective disorder (a psychiatric disorder), and other specified extrapyramidal (involving descending nerve tracts), and movement disorder.A review of the resident's quarterly Minimum Data Set (MDS) (an assessment tool), dated 3/26/26, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident was moderately cognitively impaired. Further review of the MDS revealed that the resident had a functional limitation in range of motion impairment of the upper extremities (shoulder, elbow, wrist, hand) with impairment affecting both sides and no impairment of the lower extremities (hip, knee, ankle, foot) and utilized a wheelchair for mobility. Further review of the MDS revealed that the resident had not received physical therapy services or restorative nursing programs (splint, brace assistance or range of motion) within the previous seven calendar days.A review of the resident's Care Plan Report revealed a Focus area dated 10/2/25, which indicated the resident required assistance with ADL (activities of daily living) functions. Interventions included: .Encourage use of L (left) hand brace (initiated 3/28/26) and Encourage use of b/l (bilateral) (both sides) MAFO (molded ankle foot orthosis) (used to control the foot and ankle alignment and compensate for muscle weakness).A review of the resident's Order Summary Report (OSR) revealed the following Physician's Orders (PO):A PO, dated 3/28/2026, for Encourage brace to left wrist daily.A PO, dated 3/28/2026, for Encourage B/L foot MAFO daily.A review of the March 2026 Medication Administration Record (MAR) revealed:A PO, with a D/C (Discontinue) date of 3/28/2026, for Apply B/L foot MAFO daily.A PO, with a D/C date of 3/28/2026, for Apply brace to left wrist daily.Further review of the MARS/TARS (Treatment Administration Report) revealed that there was no documented evidence that either the B/L foot MAFO or the left wrist brace were applied to the resident during the months of March, April, May or June of 2026.A review of a Provider Progress Note (PPN) dated 3/28/2026 at 1:43 PM, revealed.Pt seen in room awake, alert, and calm. Hand tremors noted.States he/she wants to do physical therapy, nursing made aware. Pt.is AAOx3 (awake, alert, and oriented).Muscoskeletal: right hand contracture.Assessment/Plan: .Physical therapy to include right hand and legs.On 6/9/2026 at 12:22 PM, Surveyor #2 observed Resident #50 lying in bed and the resident was being fed by a staff member who was seated on the left side of the resident's bed.On 6/9/2026 at 12:47 PM, Surveyor #2 met with the resident at the bedside. The resident's hands were resting on their chest and were covered by their bed sheets. The resident stated that they were supposed to wear a brace on their left hand, but no one had put it on them for about one month. The resident denied refusal and indicated that they would like to have it on.On 6/9/2026 at 12:56 PM, Surveyor #2 interviewed Certified Nursing Assistant (CNA #1) who stated that the resident required total care. CNA #1 sated that the resident's left hand was contracted, and she did range of motion with care. CNA #1 confirmed that the resident received no therapies at that time. CNA #1 stated that the resident had a splint in their drawer for their left hand which she had placed on the resident yesterday, but the resident was in pain and asked her to remove it. CNA #1 further stated that the splint was not put on today as the resident had experienced generalized pain. CNA #1 further stated that the resident had involuntary movement of their hands.On 6/10/2026 at 12:13 PM, Surveyor #2 interviewed the resident who stated that they had their splint on today for a little bit and had to have it removed due to pain. The resident denied the application of a foot MAFO or brace.On 6/10/2026 at 12:29 PM, Surveyor #2 interviewed Licensed Practical Nurse (LPN #1) who reviewed the resident's EMR and stated that the resident had no orders for either a wrist or a MAFO which should have been reflected on the MAR or TAR. LPN #1 stated that she did not know how they placed the order for the left wrist splint or the MAFO boots to the b/l lower extremities because they were not coming up in the computer. LPN #1 stated that she had been assigned to the resident since April 2026 and never saw MAFO boots. LPN #1 further stated that she had seen a left wrist splint, but that was a while ago. On 6/10/2026 at 12:39 PM, LPN #1 accompanied by Surveyor #2 entered the resident's closet with permission to look for both the MAFO boots and the left wrist splint. LPN #1 stated that the left wrist splint was in the drawer, and she confirmed that the resident did not have b/l MAFO boots. At that time, the resident agreed to allow nursing to apply the left wrist splint. LPN #1 stated that the order should have been on the MAR and/or TAR to ensure the resident received it because if it were not on there, she would not know that the resident needed it.On 6/10/2026 at 12:53 PM, Surveyor #2 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated that it had appeared that the Pain Management Doctor had seen the resident on 3/28/2026 and had written orders to encourage both the brace to left wrist daily and encourage B/L MAFO daily. LPN/UM #1 further stated the progress notes reflected that the Pain Management Doctor also wrote for Physical Therapy to include right hand and legs. LPN/UM #1 further stated that if there was a prescription, and an order that was approved by therapy, then both the splint and the MAFO should have been available for application in the resident's room.On 6/10/2026 at 1:12 PM, Surveyor #2 interviewed Occupational Therapist (OT #1) who reviewed the resident's therapy notes and stated the resident was on therapy for splinting services from 10/13/2026 through 12/2/2026 and had a Physical Therapy Evaluation on 2/14/2026. OT #1 confirmed that the resident was billed for and issued an orthotic splint after the trial and the initial fitting and it was confirmed that the resident was able to donn (put on) and doff (remove) the splint.On 6/10/2026 at 2:12 PM, Surveyor #2 interviewed the Director of Nursing (DON) who stated that the process for placing an order for a wrist splint or MAFO was to place an order in the pending orders in the EMR and once the nurse confirmed the order, the order was reflected on the MAR or TAR for the nurses to be able to sign the order off as administered. Surveyor #2 stated that the order was reviewed, and it was determined that the order was placed in the EMR by the DON on 3/28/2026 but was not reflected on the MAR or TAR as she had described. The DON stated that she had not remembered why she had placed the orders for either the wrist splint or the MAFO boots, but she thought that therapy had provided a list of those residents who were recommended to have splints, and she had updated the orders.On 6/11/2026 at 11:00 AM, Surveyor #2 interviewed the Director of Rehabilitation (DOR) who stated that he had received an order to evaluate the resident to see if there had been a decline in the resident's transfer ability on 2/14/2026, and it was determined that the resident was at baseline at that time and had no skilled need. The DOR stated that he had no information about the MAFO Boot and confirmed that it had not been issued to the resident. The DOR stated the MAFO Boot was a type of splint used to keep the resident's foot in a neutral position, but the resident was not tolerating stretching and was so contracted, that we just wanted to maintain what range of motion the resident had.At that time, the DOR further stated that the left-hand splint was more hygienic, so that staff could wash it and ensure the finger nails did not grow into the palm of the hand. The DOR stated that both the aides and nursing were educated on the hand splint on how to donn/doff it on 11/24/2025. The DOR stated that the resident preferred the hand splint during the day due to benefits with pain and stiffness. The DOR further stated that he had not recommended a scheduled wearing time because it was not fair to the resident and instead recommended to encourage use.On 6/11/2026 at 1:17 PM, Surveyor #2 interviewed the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, and she stated that she should have updated the order for the splint to ensure that the nurses had signed off on the resident's use or refusal. The DON further stated that she would have to look into it to see where she got the recommendation for the MAFO Boots from, as they had not been recommended or issued by the DOR. On 6/11/2026 at 2:19 PM, Surveyor #2 interviewed LPN #1 who demonstrated that the resident now had b/l pillow boots or heel protectors as of yesterday after surveyor inquiry to keep the resident's heels off of the bed rather than elevating them off the bed with a pillow. LPN #1 stated the resident's left hand had been contracted like that since she started working there. At that time, with resident permission, LPN #1 lifted the resident's left hand out from beneath the bed sheets and demonstrated the level of the resident's contracture. The resident's left hand was clenched towards the palm of the hand. LPN #1 stated the resident needed a new brace because the other brace did not fit and their nails were going to start cutting into the skin. LPN #1 clarified and demonstrated that the resident's nails had not cut in to their skin yet. The resident then denied pain in their palm related to their finger nails.On 6/15/2026 at 11:45 AM, The LNHA provided the surveyor with the resident's Documentation Survey Reports (DSR) that were dated from March 2026 through June 2026. A review of the DSR included an entry for Upper Body Dressing Encourage wear of L hand brace. The resident's aides documented codes of 1 (dependent) and 2 (substantial or maximum assistance) to indicate the level of staff assistance required for each task. The entry did not allow for the aides to differentiate between the two tasks or to indicate the resident's compliance or refusal. Further review of the DSR revealed an entry for Lower Body Dressing Encourage use of MAFO Boots. The entry also did not differentiate between the two tasks or indicate that that MAFO Boots were not available for application. The entries were documented with both codes of 1 and 2 to indicate the level of staff assistance provided with the task. When interviewed, the DON stated the aides should not have documented MAFO Boot use if they were not available. On 6/15/2026 at 11:58 AM, during a follow-up interview the DOR confirmed that the resident had no change in their left-hand contracture from October 2025 to present and had some improvement in his/her thumb.A review of the facility's Restorative and Contracture Management Services policy, (Revised July 2025), included: Residents will receive restorative nursing care as needed to help promote optimal safety and independence.Restorative goals may include, but are not limited to supporting and assisting the resident in: adjusting or adapting to changing abilities; .Review DME's (durable medical equipment) such as splint, boots, .etc. as needed and as ordered by the physician.NJAC 8:39-27.2(m)

Based on observation, interview, and record review, it was determined that the facility failed to review and revise a resident's comprehensive care plan to reflect changes related to a resident's skin condition and their continued risk for skin impairment. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed for pressure ulcers and was evidenced by the following. A review of the admission Record (AR), an admission summary, indicated that Resident #3 was admitted to the facility with the diagnoses which included but was not limited to; chronic obstructive pulmonary disease (COPD), diabetes mellitus, heart failure and chronic peripheral venous insufficiency (when the leg veins do not allow the blood to flow freely back up to the heart).A review of the quarterly Minimum Data Set (MDS) an assessment that facilitates a resident's care, dated 5/21/2026. indicated that the resident scored 14 out of 15 on the Basic Interview for Mental Status (BIMS), an assessment tool, which indicated that the resident was cognitively intact. Further review of the MDS indicated that the resident required maximum assistance with mobility, dressing, toileting and personal hygiene and was at risk of developing pressure ulcers. The MDS also indicated that the resident had a stage 4 (four) pressure ulcer (The most severe form of pressure injury, where tissue damage extends through all layers of skin with exposed muscle, tendon, ligament, or cartilage visible or that can be felt via touch within the wound). On 6/9/2026 at 10:15 AM, the surveyor observed Resident #3 lying in bed with oxygen infusing at 2 (two) liters by way of nasal cannula (oxygen tubing). Resident #3 stated they felt okay and was breathing better after being treated for pneumonia. The resident stated that they did not know if they had a pressure ulcer but stated that they had something on their foot but had no pain or discomfort. The surveyor did not observe any specialty mattress on the bed or any anti-pressure devices on the resident's bilateral feet.On 6/10/2026 at 8:28 AM, the surveyor reviewed Resident #3's electronic medical record (EMR) which revealed the following information:A review of the nurse's Progress Notes (PN) dated 6/9/2026 at 11:48 AM, indicated that Resident #3 was sent to the emergency room department ( ED) for congestive heart failure exacerbation.A review of Resident #3's Treatment Administration Record (TAR) indicated that the resident's treatments to the left heel were discontinued on 5/28/26.A review of the TAR also revealed the treatments to the residents left plantar foot and right lateral ankle were discontinued on 5/13/2026.A review of the surgical wound note dated 5/27/2026, indicated that Resident #3's left heel ulcer was healed and that the plan was to continue offloading and turning as per facility protocol.A review of Resident #3's Interdisciplinary Comprehensive Care Plan (ICCP) revealed that the care plans addressing the left heel wound and left plantar wounds were resolved on 5/26/26. However, the ICCP was not revised to reflect the resident's ongoing risk for skin breakdown despite diagnoses, functional limitations, history of wounds, and risk factors for impaired skin integrity. The care plan did not contain interventions directed toward preventing future skin impairment and maintaining skin integrity.On 6/10/2026 at 9:17 AM, the surveyor interviewed Resident #3's primary care Licensed Practical Nurse (LPN #1) who stated that Resident #3's wounds on the left heel and plantar had recently healed. She further stated that while the resident should have been care planned for actual skin impairment when the wounds were present, the care plan should have been revised after healing to address the resident's continued risk for skin breakdown and altered skin integrity. LPN #1 explained that updated care plan interventions would provide nursing staff with guidance regarding measures necessary to prevent recurrence of wounds and to maintain skin integrity. On 6/10/2026 at 10:00 AM, the surveyor interviewed the licensed Practical Nurse Unit Manager (LPN/UM #1) who reviewed Resident #3's ICCP in the presence of the surveyor and confirmed that the resident did not have an ICCP for alteration in skin integrity or potential for skin impairment. She stated that there was an ICCP that resolved the left heel and plantar wound on the 5/26/26, however the ICCP was not updated to include interventions related to the resident's continued risk for skin impairment.On 6/15/2026 at 9:52 AM, during an exit meeting with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), the DON acknowledged that Resident #3's ICCP should have been revised following wound healing to address the resident's ongoing risk for altered skin integrity and include appropriate preventative interventions.A review of the facility policy dated March 2022 and titled, Care Plans, Comprehensive Person-Centered indicated that the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when a desired outcome is not met, when the resident is readmitted from a hospital stay, at least quarterly in conjunction with the required quarterly MDS assessment. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure: a.) a physician's order was clarified, and b) obtain a physician's order to crush a resident's medication for 1 of 5 residents (Resident #8) reviewed for unnecessary medication. This deficient practice was evidenced by the following:Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 6/08/2026 at 10:45 AM, the surveyor observed Resident #8 resting in bed. On 6/09/2026 at 8:41 AM, the surveyor reviewed Resident #8's electronic medical record (EMR). A review of the admission Record, an admission summary, revealed the resident had a diagnosis which included, but was not limited to; hemiplegia (paralysis or severe weakness on one side of the body) hemiparesis (muscle weakness affecting only one side).A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/5/2026, included that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident's cognition was severely impaired.A review of the physician's orders (PO) included docusate sodium oral capsule 100 milligrams (MG), give 2 capsule by mouth one time a day for bowel regimen 2 tabs (tablets) =100 MG.On 6/10/2026 at 12:05 PM, the surveyor interviewed Licensed Practical Nurse (LPN#2) who stated that she was assigned to Resident #8 and had administered their morning medication to them. The surveyor asked LPN #2 what form of docusate and dosage was administered to the resident that morning. LPN #2 pulled out the bottle of docusate sodium 100 Mg tablets and stated that she administered two tablets to the resident. She added that she crushed the docusate sodium tablets because that was how they take it. The surveyor requested that LPN #2 pull up the resident's EMR. At that time, LPN #2 reviewed the order for docusate and stated that the total dosage should be 200 MG and she would clarify the medication order with the provider. She added that the order should have been clarified when it was given.On 6/10/2026 at 12:42 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager ( LPN/UM #1) who stated the nurse should contact the doctor right away if they needed clarification of a medication. LPN/UM #1 stated that she was unsure if a physician's order was required to crush medications.On 06/11/2026 at 9:21 AM, the surveyor interviewed the Director of Nursing (DON) who stated that if a physician's order was unclear, it should be clarified with the provider right away. She also added that a PO should be obtained to crush a resident's medication. A review of the facility's Physician Medication and Treatment Orders policy, reviewed July 2025, included . Medication orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered.NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it has been determined that the facility failed to ensure that a resident receiving dialysis had their medications scheduled around their dialysis times to ensure that the resident did not miss routinely scheduled medications. This deficient practice was identified for 1 of 2 residents (Resident #12) reviewed for dialysis and was evidenced as follows:On 6/9/2026 at 11:31 AM, the surveyor observed Resident # 12 seated in a wheelchair, being escorted by staff down the hallway. Resident #12 stated that they were on their way to their dialysis appointment.The surveyor reviewed the electronic medical record (EMR) for Resident #12.A review of the admission Record, an admission summary, revealed that Resident #12's diagnoses included, but were not limited to; Dependence on Dialysis (A life-sustaining medical treatment that performs the natural filtering functions of the kidneys) and End Stage Renal Disease (the final, most severe stage of chronic kidney disease).A review of Resident #12's Quarterly Minimum Data Set (MDS), an assessment tool dated 5/1/2026, revealed the resident's Brief Interview for Mental Status (BIMS) (a cognitive screening) scored a 14 out of 15, which indicated that the resident's cognition was intact. A further review of the MDS revealed that Resident #12 was receiving dialysis.A review of Resident #12's individual comprehensive care plan (ICCP) included a focus area, dated 4/25/2026, revealed that Resident #12 was on dialysis. The interventions included but were not limited to; dialysis three times per week (Tuesday, Thursday, and Saturday), and to adjust the medications to continue to be administered as ordered, and alter times as provider orders to ensure all due medications are administeredA review of Resident #12's Order Summary Report revealed the following physician's order (PO) :A PO, dated 4/27/2026 for dialysis, chair time 11:30 AM, pickup time 10:40 AM, and return time 3:30 PM. The physician's order did not include the days that Resident #12 attended dialysis.A review of Resident #12's Medication Administration Record (MAR) for April 2026 revealed that the resident was ordered sevelamer carbonate 800 mg tablet for chronic kidney disease, give two tablets by mouth, three times a day (7:30 AM, 11:45 AM, and 4:45 PM). On 4/25/2026, the 11:45 AM dose was documented as not administered, evidenced by code #9 (see progress notes). A review of a progress note dated 4/25/2026 at 11:38 AM, revealed that the sevelamer carbonate 800 mg tablet was not administered due to the resident being out for dialysis. A further review of the MAR revealed that on 4/28/2026, the resident did not receive their sevelamer carbonate 800 mg 11:45 AM dose, evidenced by a code 1 which indicated that the resident was not at the facility at that time.A review of Resident #12's MAR for May 2026 revealed that the resident was ordered isosorb dinitrate-hydralazine 20-37.5 mg tablet, give two tablets by mouth, three times per day (8:00 AM, 2:00 PM, and 8:00 PM) for congestive heart failure/hypertension. On 5/5/2026, the 2:00 PM dose was documented as not administered, evidenced by a code 15 that the resident was out for dialysis. A further review of the May MAR revealed that on 5/9/2026, the resident did not receive their 2:00 PM dose, evidenced by a code 9 (see progress notes). A progress note dated 5/9/2026 at 1:35 PM revealed that the resident was out for dialysis. It was also noted that on 5/19/2026, the resident did not receive the 2:00 PM dose, evidenced by a code 9. There was no progress note for that missed dose. A further review revealed that on 5/21/2026, the 2:00 PM dose was not administered, evidenced by a code 15 for dialysis. A progress note dated 5/21/2026 at 1:13 PM revealed Resident at dialysis. According to the MAR, it was also noted that on 5/23/2026, the 2:00 PM dose was not administered, evidenced by code 9. A review of the progress note dated 5/23/2026 at 1:29 PM, revealed that the resident was out for dialysis.A further review of the May 2026 MAR revealed that Resident #12 still had an active order for the sevelamer carbonate 800 mg tablet for chronic kidney disease, give two tablets by mouth, three times a day (7:30 AM, 11:45 AM, and 4:45 PM). On 5/12/2026 and 5/23/2026, the 11:45 AM dose was not administered as evidenced by a code 15 (dialysis).It was also noted that on 5/27/2026, the medication administration time for sevelamer carbonate 800 mg was changed to 8:00 AM, 2:00 PM, and 8:00 PM. On 5/28/2026 and 5/30/2026, the 2:00 PM dose of sevelamer carbonate was not administered as evidenced by a code 1 which indicated that the resident was absent from the facility without medication. A review of the progress note dated 5/30/2026 at 5:53 PM revealed that the resident was at dialysis.A review of the June 2026 MAR revealed that Resident #12's order for sevelamer carbonate 800 mg tablet three times a day (8:00 AM, 2:00 PM, and 8:00 PM) continued. On 6/2/2026 and 6/9/2026, the 2:00 PM dose was not administered as evidenced by the code 15, which indicated that the resident was at dialysis.On 6/10/2026 at 9:30 AM, the surveyor interviewed Licensed Practical Nurse (LPN #2) who stated that a physician's order was required for a resident who attended dialysis and it should include the dialysis days and times. She added that when a resident was scheduled for dialysis, their medications and treatment should be scheduled around their dialysis time. She also stated that if they missed a dose of medication, the doctor should be informed of the missed dose.On 6/10/2026 at 10:35 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated that Resident #12 went out for dialysis on Tuesdays, Thursdays and Saturdays. She added that there should be a physician's order that included the days and times that the resident goes out for dialysis. She further stated that the medications should be plotted around their dialysis times to make sure that resident get their medication and nothing was missed.On 6/11/2026 at 9:13 AM, the surveyor interviewed the Director of Nursing (DON) who stated that when a resident goes out for dialysis, the facility should make sure that their medications were plotted around their dialysis times, so medication administration was not missed or delayed, because it was important for them to receive all their meds. She further stated that the doctor should have been notified of any missed medications, so the order could be clarified, because communication with the doctor was key.A review of the facility's Hemodialysis policy, last reviewed August 2025, included .Treatment and medication orders at the facility will be scheduled to accommodate facility absence for Dialysis treatment and or per Physician order.NJAC 8:39-27.1(a)-29.2(d)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to ensure that all Drug Enforcement Administration (DEA) 222 forms were completed with sufficient detail to enable accurate accountability and reconciliation for controlled medications. This deficient practice was identified for 2 of 10 DEA 222 forms reviewed in 1 of 1 back up controlled medication storage area and was evidenced by the following:On 6/11/2026 at 10:00 AM, the surveyor reviewed the facility's DEA 222 form records for the backup-controlled medication storage and noted that on 3/5/2025, and 6/17/2025, Part 5 of the DEA 222 forms were incomplete. Specifically, the purchaser failed to document the quantity of controlled medications that were received. On 6/11/2026 at 10:09 AM, the surveyor interviewed the Director of Nursing (DON) regarding incomplete DEA 222 forms. The surveyor reviewed the forms with the DON and noted that Part 5, which specified the quantity of controlled medications received by the purchaser, had not been completed. The DON stated that staff were expected to verify and count all controlled medications received to ensure the shipment was accurate and complete. The DON acknowledged that Part 5 of the DEA 222 form should have been filled out correctly. The DON further stated that documenting the quantity received served as an important part of the check-and-balance process. On 6/11/2026 at 12:53 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team and the LNHA confirmed that the quantity of controlled substances received should have been documented on the DEA form 222. On 6/15/2026 at 10:20 AM, the surveyor interviewed Pharmacist #1 by telephone regarding the DEA form 222 completion process. Pharmacist #1explained that Part 5 of the DEA 222 form must be completed by the purchaser, which in this case was the nursing home. The pharmacist indicated that the facility was responsible for documenting the quantity of controlled medications received upon delivery. The pharmacist explained that completion of Part 5 of the form was important for accountability and diversion (theft) prevention and further stated that there should not have been blank fields in Part 5 of the DEA 222 form. On 6/15/2026 at 10:55 AM, the surveyor conducted a telephone interview with the Pharmacy Consultant (PC) who stated the PC reviewed the DEA 222 form records to verify that quantities documented matched the quantities received to ensure the forms were completed accurately. The PC stated that she checked the forms at the facility about every three months, but she had not looked back that far since she had started working at the facility in January of 2026. At that time, the PC was made aware of the DEA 222 forms dated 3/15/2025 and 6/17/2025, and specified that Part 5 was not filled in by purchaser to indicate the quantity of controlled medications received. PC confirmed that she did not identify the discrepancy with the DEA 222 form because she was not the PC in the facility at the time the DEA 222 form errors occurred. The PC further stated if errors were found on the DEA 222 form they should have been brought to the attention of the DON. A review of the facility's Controlled Substances policy dated August 2025 included Dispensing and Reconciling Controlled Substances .The consultant pharmacist or designee routinely monitors controlled substance storage records.The Director of Nursing or designee will monitor DEA 222 form completion, delivery manifests, and reconcile medication received . NJAC- 8:39-29.7 (C)

Based on interviews, review of the medical record, and pertinent facility documents, it was determined that the facility failed to ensure that staff accurately documented a resident skin condition in the medical records in accordance with accepted professional standards and practice. This deficient practice was identified for 1 of 3 residents reviewed for pressure ulcers (Resident #3) and was evidenced by the following:A review of the admission Record (AR), an admission summary, indicated that Resident #3 was admitted to the facility with the diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD), diabetes mellitus, heart failure and chronic peripheral venous insufficiency.A review of the quarterly Minimum Data Set (MDS), an assessment tool that facilitates a resident's care, dated 5/21/2026, indicated that the resident scored 14 out of 15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident was cognitively intact. Further review of the MDS indicated that the resident required maximum assistance with mobility, dressing, toileting and personal hygiene and was at risk of developing pressure ulcers. The MDS also indicated that the resident had a stage 4 (four) pressure area (Full-thickness skin and tissue loss, exposing underlying fascia, muscle, tendon, ligament, tendon or bone).On 6/9/2026 at 10:15 AM, the surveyor observed Resident #3 lying in bed with oxygen infusing at 2 (two) liters by way of nasal cannula (oxygen tubing). Resident #3 stated they felt ok and was breathing better after being treated for pneumonia. The residents stated that they did not know if they had a pressure ulcer but stated that they had something on the foot but had no pain or discomfort. The surveyor did not observe any specialty mattress on the bed or any anti-pressure devices on the resident's bilateral feet.On 6/10/2026 at 8:28 AM, the surveyor reviewed Resident #3's electronic medical record (EMR) which revealed the following information:A review of the nurse's Progress Notes (PN) dated 6/9/2026 at 11:48 AM, indicated that Resident #3 was sent to the emergency room department ( ED) for congestive heart failure exacerbation.A review of Resident #3's Treatment Administration Record (TAR) indicated that the resident's treatments to the left heel were discontinued on 5/28/26.A review of the TAR also revealed the treatments to the residents left plantar foot and right lateral ankle were discontinued on 5/13/2026.A review of the surgical wound note dated 5/27/2026 indicated that Resident #3's left heel ulcer was healed and that the plan was to continue offloading and turning as per facility protocol.A review of the skilled charting dated 6/9/26 at 12:50 PM indicated the following: SKIN/WOUND Resident is receiving wound care. Wound etiology is Pressure injury/wounds. Wound Base- Granulation tissue: red, moist, bumpy tissue indicating healing. Wound Drainage Amount - Large/copious. Wound Drainage Type - Serous: clear or pale yellow, thin, watery. Wound Odor - None. Wound Perimeter - Intact: normal skin, no breakdown. Nursing care required for wound care: Wound care rendered. Further review of the resident's medical record revealed no documented pressure ulcers or active wounds at the time this entry was made.A review of the skilled charting dated 6/6/2026 at 11:20 AM revealed the following entry: SKIN/WOUND Resident is receiving wound care. Wound etiology is Pressure injury/wounds. Wound Base- Granulation tissue: red, moist, bumpy tissue indicating healing. Wound Drainage Amount - Large/copious. Wound Drainage Type - Serous: clear or pale yellow, thin, watery. Wound Odor - None. Wound Perimeter - Intact: normal skin, no breakdown. Nursing care required for wound care: Wound care rendered. Further review of the resident's medical record revealed no documented pressure ulcers or active wounds at the time this entry was made.On 6/10/2026 at 9:17 AM, the surveyor interviewed Resident #3's primary care Licensed Practical Nurse (LPN #1) who stated that Resident #3's wounds on the left heel and planter have recently been resolved. The LPN explained that she had documented a health status note in the EMR on 6/9/2026 at 11:54 AM and 6/6/26 at 11:20 AM, indicating that the resident had a pressure ulcer and was receiving wound care. LPN #1 could not explain why she had documented that the resident was receiving wound care and had a pressure ulcer when the residents' wounds had healed.A review of the health status note dated 6/5/2026 at 12:14 PM indicated: INTEGUMENTARY Pressure Ulcers: Positive, Foot Ulcers: Positive Poor, Healing of Wounds: Positive, Hair Loss: PositiveOn 6/11/2026 at 12:11 PM, the surveyor interviewed a Registered Nurse (RN #1) employed by a managed care organization who authored the health Status note date 6/5/2026 at 12:14 PM. The RN stated that he personally assessed residents during his visits. The RN further stated that during his assessment of Resident #3 on 6/5/2026, he believed the resident had a pressure ulcer and foot ulcer. When informed that the facility documentation indicated that the resident's arterial and heel ulcers had healed prior to the 6/5/2026 assessment, the RN acknowledged that the documentation may have been entered in error.On 6/11/2026 at 12:26 PM, the surveyor attempted to telephone interview the primary care physician. No answer, message left.On 6/11/2026 at 12:28 PM, the surveyor interviewed the Medical Director (MD) regarding electronic medical record (EMR) discrepancies. The MD acknowledged that the medical documentation does not always accurately reflect real-time patient status, noting a systemic lag between physician notes and physical assessments. He identified this redundancy and delay as a systemic healthcare failure rather than an isolated incident. He agreed that documentation practices required immediate remediation and stated he would address these standards with the facility's nursing and medical staff. The MD concluded, We will continue to strive for better documentation in this healthcare facility.A subsequent review of the provider progress note dated 5/30/2026 at 17:12 [5:12 PM], authored by the nurse practitioner (NP), indicated that Resident #3 presented with a left heel stage 4, bilateral venous statis, and dermatitis. Documented recommendations included offloading the left heel, continuing with current treatments protocols, consulting with a wound specialist and application of a boot to offload the left and right foot.On 6/15/2026 at 9:08 AM, the surveyor interviewed the Nurse Practitioner (NP #1) responsible for primary care coverage on 5/30/2026 and who authored the provider progress note dated 5/30/2026 at 5:12 PM. NP #1 stated that she performed a comprehensive, all systems evaluation on Resident #3 and documented her findings accordingly. However, upon reviewing the PN during the interview, NP #1 acknowledged a documentation omission, noting the text failed to indicate that Resident #3's left foot wounds had healed. NP #1 conceded that an error was made and clarified that she should have documented the improvement and healing of the wounds. NP #1 expressed regret for the oversight and committed to improving documentation accuracy moving forward.On 6/15/2026 at 9:52 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) in the presence of the survey team, and both indicated that in-servicing needed to be conducted with staff regarding accurate and consistent documentation and also that the MD would need to in-service physicians regarding accurate documentation in the EMR. The facility policy dated July 2017, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.NJAC 8:39-35.2 (d)(6)

Complaint #: 2601823, 421288, 2646782Based on interviews, medical record review, and review of pertinent facility documentation on 1/2/26 and 1/5/26, it was determined that the facility failed to consistently document Activities of Daily Living (ADL) as being provided to residents for 5 of 5 residents reviewed for ADLs. The facility also failed to follow its policy titled, Activities of Daily Living (ADLs)/Maintain Abilities. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted with diagnoses that included but were not limited to: End Stage Renal Disease (ESDR) and Dialysis.According to the Minimum Data Set (MDS), an assessment tool dated 12/29/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) that was not completed at the time of survey due to recent admission. A review of Resident #1's Care Plans (CP) with a focus of Decline in functional status reveals an initiation date of 12/30/2025 and an intervention of provide and assist with ADL.A review of Resident #1's December 2025 Documentation Survey Report v2, a form used to document ADL care and often referred to as Point of Care (POC) included blank spaces indicating that the following tasks were not completed:Bladder Elimination and Bowel Elimination on 12/30/25 on the evening shift. On 12/31/25 on the night shift.Eating on 12/30/25 on the evening shift.Amount Eaten on 12/30/25 on the evening shift. 2. According to the AR, Resident #2 was admitted with diagnoses that included but were not limited to: Chronic Kidney Disease (CKD) and Diabetes.According to the MDS, an assessment tool dated 7/10/2025, Resident #2 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. A review of Resident #2's CP with a focus of Decline in functional status reveals an initiation date of 12/30/2024 and an intervention of provide and assist with ADL.A review of Resident #2's July 2025 Documentation Survey Report v2, a form used to document ADL care and often referred to as POC, included blank spaces indicating that the following tasks were not completed:Bladder Elimination and Bowel Elimination on 7/5/25, 7/6/25, 7/7/25, 7/11/25, 7/13/25, 7/15/25, 7/16/25, 7/17/25, 7/21/25, 7/27/25, 7/28/25, and 7/30/25 on the day shift. On 7/1/25, 7/4/25, 7/6/25, 7/7/25, 7/11/25, 7/13/25, 7/15/25, 7/18/25, 7/19/25, 7/26/25, 7/29/25, and 7/30/25 on the evening shift. On 7/1/25, 7/3/25, 7/9/25, 7/10/25, 7/11/25, 7/13/25, 7/16/25, 7/17/25, 7/28/25, and 7/31/25 on the night shift.Eating on 7/5/25, 7/6/25, 7/7/25, 7/11/25, 7/13/25, 7/15/25, 7/16/25, 7/17/25, 7/21/25, 7/27/25, 7/28/25, and 7/30/25 on the day shift. On 7/1/25, 7/4/25, 7/6/25, 7/7/25, 7/13/25, 7/15/25, 7/18/25, 7/19/25, 7/26/25, 7/29/25, and 7/30/25 on the evening shift. Amount Eaten on 7/5/25, 7/6/25, 7/7/25, 7/11/25, 7/13/25, 7/15/25, 7/16/25, 7/17/25, 7/21/25, 7/27/25, 7/28/25, and 7/30/25 on the day shift for the 0700 and 1200 hours. On 7/1/25, 7/4/25, 7/6/25, 7/7/25, 7/13/25, 7/15/25, 7/18/25, 7/19/25, 7/26/25, 7/29/25, and 7/30/25 on the evening shift.A review of Resident #2's August 2025 Documentation Survey Report v2, a form used to document ADL care and often referred to as POC, included blank spaces indicating that the following tasks were not completed:Amount Eaten on 8/8/25 on the evening shift. 3. According to the AR, Resident #3 was admitted with diagnoses that included but were not limited to: Dementia.According to the MDS, an assessment tool dated 10/10/2025, Resident #3 had a BIMS score of 8 out of 15, which indicated the resident was moderately impaired. A review of Resident #3's CP with a focus of Currently requires extensive assistance with ADL tasks. reveals an initiation date of 7/24/2025 and an intervention of provide and assist with ADL.A review of Resident #3's September 2025 Documentation Survey Report v2, a form used to document ADL care and often referred to as POC, included blank spaces indicating that the following tasks were not completed:Bladder Elimination and Bowel Elimination on 9/20/25, 9/21/25 and 9/29/25 on the day shift. On 9/11/25 and 9/27/25 on the evening shift. On 9/13/25 and 9/30/25 on the night shift.Eating on 9/19/25, 9/20/25, 9/21/25 and 9/29/25 on the day shift. On 9/11/25 and 9/27/25 on the evening shift. On 9/13/25 and 9/30/25 on the night shift.Amount Eaten on 9/20/25 and 9/29/25 on the day shift for the 0700 hour and 9/13/25, 9/20/25 and 9/29/25 on the day shift for the 1200 hour. On 9/11/25 and 9/27/25 on the evening shift.A review of Resident #3's October 2025 Documentation Survey Report v2, a form used to document ADL care and often referred to as POC, included blank spaces indicating that the following tasks were not completed:Bladder Elimination and Bowel Elimination on 10/1/25, 10/26/25 and 10/29/25 on the day shift. On 10/4/25, 10/20/25, 10/24/25, 10/30/25, and 10/31/25 on the evening shift. On 10/5/25, 10/13/25, 10/27/25, and 10/31/25 on the night shift.Eating on 10/1/25, 10/26/25 and 10/29/25 the day shift. On 10/4/25, 10/20/25, 10/24/25, 10/30/25, and 10/31/25 on the evening shift. On 10/5/25, 10/13/25, 10/27/25, and 10/31/25 on the night shift.Snacks 4oz Magic Cup with lunch and dinner on 10/1/25, 10/26/25, 10/29/25, and 10/31/25 on the day shift for the 1200 hour. On 10/4/25, 10/20/25, 10/24/25, 10/30/25, and 10/31/25 on the evening shift for the 1730 hour. 4. According to the AR, Resident #4 was admitted with diagnoses that included but were not limited to: Chronic obstructive pulmonary disease.According to the MDS, Resident #4 had a BIMS that was not completed at the time of survey due to recent admission. A review of Resident #4's December 2025 Documentation Survey Report v2, a form used to document ADL care and often referred to as POC included blank spaces indicating that the following tasks were not completed:Bladder Elimination and Bowel Elimination on 12/29/25 and 12/31/25 on the day shift. On 12/25/25, 12/27/25, 12/30/25, and 12/31/25 on the evening shift. On 12/27/25 on the night shift.Eating on 12/29/25 and 12/31/25 on the day shift. On 12/25/25, 12/27/25, 12/30/25, and 12/31/25 on the evening shift.Amount Eaten on 12/29/25 and 12/31/25 on the day shift for the 0700 hour and on 12/29/25, 12/30/25, and 12/31/25 for the 1200 hour. On 12/25/25, 12/27/25, 12/30/25, and 12/31/25 on the evening shift for the 1700 hour. 5. According to the AR, Resident #5 was admitted with diagnoses that included but were not limited to: ESDR and CKD.According to the MDS, an assessment tool dated 12/4/2025, Resident #5 had a BIMS score of 5 out of 15, which indicated the resident was severely impaired. A review of Resident #5's CP with a focus of Q1 REVIEW -9/11/25 -no change in ADL functions-cont. with POC reveals an intervention of provide and assist with ADL.A review of Resident #5's November 2025 Documentation Survey Report v2, a form used to document ADL care and often referred to as POC included blank spaces indicating that the following tasks were not completed:Bladder Elimination and Bowel Elimination on 11/03//25, 11/26/25, and 11/27/25 on the day shift. On 11/1/25, 11/2/25, 11/12/25, 11/18/25, 11/19/25, and 11/21/25 on the evening shift. On 11/10/25, 11/12/25, 11/21/25, 11/25/25, and 11/30/25 on the night shift.Eating on 11/03//25, 11/26/25, and 11/27/25 on the day shift. On 11/1/25, 11/2/25, 11/18/25, 11/19/25, and 11/21/25 on the evening shift.A review of Resident #5's December 2025 Documentation Survey Report v2, a form used to document ADL care and often referred to as POC included blank spaces indicating that the following tasks were not completed:Bladder Elimination and Bowel Elimination on 12/15/25, 12/21/25, 12/22/25, 12/23/25, 12/24/25, 12/26/25, 12/29/25, and 12/31/25 on the day shift. On 12/1/25, 12/4/25, 12/5/25, 12/11/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/21/25, 12/23/25, 12/24/25, 12/25/25, 12/29/25, and 12/31/25 on the evening shift. On 12/4/25, 12/7/25, 12/18/25, 12/19/25, 12/21/25, 12/30/25, and 12/31/25 on the night shift.Eating on 12/15/25, 12/21/25, 12/22/25, 12/23/25, 12/24/25, 12/26/25, 12/29/25, and 12/31/25 on the day shift. On 12/1/25, 12/4/25, 12/5/25, 12/11/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/21/25, 12/23/25, 12/24/25, 12/25/25, 12/29/25, and 12/31/25 on the evening shift.Amount Eaten on 12/15/25, 12/21/25, 12/22/25, 12/23/25, 12/24/25, 12/26/25, 12/29/25, and 12/31/25 on the day shift for the 0700 and 1200 hours. On 12/1/25, 12/4/25, 12/5/25, 12/11/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/21/25, 12/23/25, 12/24/25, 12/25/25, 12/29/25, and 12/31/25 on the evening shift for the 1700 hour.During an interview on 1/5/26 at 9:33 A.M. with the Certified Nursing Assistant (CNA), the CNA states that for the ADL's everyone should be completing them daily. She further stated that she completes them mid shift and at the end of her shift on the POC's and if it is not documented then it's not done. During an interview on 1/2/26 at 1:42 P. M. with the Licensed Practical Nurse (LPN), the LPN stated the CNA's complete the POC documentation and if it's not documented then it's not done.During an interview on 1/5/26 at 11:10 A. M. with the [NAME] President of Nursing and Clinical Services (VP), the VP states the X's noted on the POC's are for PRN or as needed services. The blanks are when no one has documented for that shift and there's no way to know if it's done. If it's not documented, it's not done.Review of the facility's policy titled Activities of Daily Living (ADLs)/Maintain Abilities dated 05/01/25, revealed under Procedure: .3. The facility will provide care and services for the following activities of daily living: .c. Elimination-toileting, d. Dining-eating, including meals and snacks.Review of the facility's document titled Nursing Documentation, dated 05/01/25, revealed under Documentation Requirements .3. Documentation: .Document all nursing interventions and observations, including but not limited to: Activities of Daily Living (ADLs) and assistance required if applicable. NJAC 8:39-27.1 (a)NJAC 8:39-27.1 (b)

C/O # NJ 182995 Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to provide adequate supervision for a cognitively impaired resident with a known history of aggressive exit seeking which resulted in the resident eloping on 12/12/2024. This deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident #160). Resident #160, who was cognitively impaired with a known history of aggressive exit seeking, eloped from the facility on 12/12/2024. The staff reported last seeing Resident #160 in the dining room between 05:00 PM and 05:30 PM on 12/12/2024. The resident wore a wander guard to their left ankle that the physician ordered to be checked for placement and function every shift, and was last checked on 12/12/2024 at 02:00 PM. On 12/12/2024 at 07:40 PM, the Registered Nurse (RN #1) reported that the resident was not in their room to receive their medication. Between 08:00 PM and 09:00 PM, the Certified Nursing Assistant (CNA #3) could not locate Resident #160, and he observed that the resident did not eat their dinner. At 09:30 PM, CNA #3 searched the building and alerted RN #1 that Resident #160 could not be found. The facility management and staff began a search for the resident both inside and outside the facility and notified the local police. The police, along with a canine (K-9; police dog) blood hound and drone searched for Resident #160, and the police located the resident on the property in the trees on 12/13/2024 at 01:45 AM. Resident #160 was immediately sent to the hospital and the resident was admitted with hypothermia (body temperature lower than 95 degrees Fahrenheit (F), normal temperature 97.7 to 99.5 degrees F) and elevated white blood cells (WBC). The facility's failure to provide adequate supervision to a cognitively impaired resident who was at risk for elopement and eloped posed a likelihood of serious harm, injury, impairment or death. This resulted in an Immediate Jeopardy (IJ) situation which ran from 12/12/2024 at 05:30 PM, when Resident #160 was last seen by staff, until 12/13/2024 at 01:45 AM, when the police located the resident and sent them to the hospital. The IJ was Past Non-Compliance (PNC). The PNC IJ was identified from 12/12/2024 at 05:30 PM, which continued to 12/13/2024 at 01:45 AM, when the resident was found and sent to the hospital for evaluation. The facility was back in compliance when the facility addressed the situation by immediately searching and locating the resident; the resident was sent to the hospital for evaluation; the wander guard system was checked for function; all wander guards were checked; and all staff were inserviced on the facility's elopement protocol. The facility Administration was notified of the PNC IJ on 01/30/2025 at 04:31 PM. The facility submitted an acceptable Removal Plan (RP) on 01/31/2025 at 01:15 PM. The facility team verified the completion of the Removal Plan was 12/30/2024, during the on-site survey on 01/31/2025, and determined the IJ was PNC. The evidence was as follows: A review of a facility policy titled Elopement dated 05/01/2024, revealed under the Intent section; It is the intent of the facility to be aware of its resident's usual habits and locations as reasonably practical. This is with the intent of not invading privacy but to identify a possible missing resident. A review of the electronic Medical Record (EMR) on 01/30/2025 at 02:20 PM, revealed the following: According to the Admission Record face sheet (an admission summary) Resident #160 was admitted with diagnoses including but not limited to; unspecified dementia. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 09/26/2024, revealed Resident #160 had a Brief Interview for Mental Status (BIMS) score of 4/14 indicating Resident #160 was severely cognitively impaired. A further review of the MDS indicated the resident was independently ambulatory with no assistive devices and used a wander/elopement alarm daily. A review of Resident #160's individualized comprehensive care plan (ICCP) included a focus area of at risk for wandering/elopement. Goals included that the resident will not leave the facility unattended. Interventions included to: engage resident in purposeful activity initiated on 10/03/2024; provide care in a calm and reassuring manner initiated on 10/03/2024; provide clear simple instructions initiated on 10/03/2024; and wander guard bracelet as ordered to right ankle and left ankle, check placement and function as ordered initiated on 10/03/2024. A review of the Order Summary Report revealed a physician's order dated 06/23/2024, for wander guard on right ankle; to check placement and function every shift. A review of the Medication Administration Record (MAR) dated 12/1/2024-12/31/2024, revealed the physician's order for the wander guard was signed as having been checked for placement and function on 12/12/24 at 06:00 AM and 02:00 PM. A review of an Elopement Evaluation dated 09/26/2024, revealed a score of 5 and that the resident was identified for the following risks; a history of elopement or attempted leaving the facility without informing staff, resident wanders, resident wanders aimlessly or non-goal directed, wander behavior likely to effect the safety or well-being of self/others, and the resident's wandering behavior likely to effect the privacy of others. The evaluation indicated that score of 1 or higher indicated a risk of elopement. A review of the progress notes (PN) dated 11/27/2024 at 11:47 PM, included the resident did not have the wander guard at this time; resident stated that I keep it somewhere. A PN dated 11/28/2024 at 11:10 PM, indicated the resident was calling out hallucinations to oncoming staff; the resident had increased agitation during this shift. A PN dated 11/29/2024 at 11:13 PM, revealed Left ankle wander guard is not functional. Noted resident connected with sharp Nails. ??? [sic] Made aware Nursing Supervisor and shift charge to follow up. A PN dated 11/30/2024 at 12:03 AM, revealed the resident took off their wander guard. A PN dated 11/30/2024 at 05:37 AM, revealed the resident did not have their wander guard on. A PN dated 12/12/2024 at 07:40 PM, indicated the resident was not in their room to receive medication. A PN dated 12/13/2024 at 02:25 AM, revealed the resident was transferred out to the hospital. A review of the facility's Investigation and Summary and Conclusion dated 12/17/2024, revealed the following: under the background section: resident had a history of wandering aimlessly and exit seeking for which interventions have been put into place. Resident wore a wander guard to right ankle. Under the timeline of Events on 12/12/2024, included the following: At approximately (approx) 05:30 PM-06:00 PM, the resident was observed in dining room. At approx 08:00 PM-09:00 PM, CNA #3 went to check on the resident and observed dinner was not touched. At approx 09:30 PM, CNA # 3 initiated a search for the resident. At approx 10:00 PM, management was notified; head count completed; search in the facility and surrounding areas outside of the facility. The outdoor areas were checked by the management team; all doors and wander guard system checked by the Director of Maintenance (DOM) and all wander guards worked properly. At approx 10:15 PM, the family was notified by Director of Nursing (DON). At approx 10:45 PM, the local police department was notified, and the police were on site at approximately 11:00 PM. At approx 11:30 PM, the local police department completed search inside the facility and initiated search outside. The K-9 unit was on-site and not successful. On 12/13/2024: At approx 12:30 AM, the search continued with a different K-9 and drone. From approx 12:30 AM-01:30 AM, the management and corporate team continued with search with address on record and other addresses as recommended by the family. During conversation with family, the [family member redacted] mentioned other locations where the resident could be found. At approx 01:45 AM, the resident was transferred to the hospital for evaluation. At approx 02:00 AM, the Department of Health (DOH) was called to report the event. At approx 10:45 AM, the facility called hospital; the resident was admitted to hospital with elevated WBC. At approx 02:18 PM, the Ombudsman was notified by the LNHA. Under the Interventions in place to prevent future incident included: plan of care reviewed and updated; one-to-one (1:1) supervision; will continue with wander guard; ensure list with at risk for elopement residents placed at front desk; facility wide education completed for elopement protocol; will consider higher level of care for safety-dementia unit; and all wander guards inspected for safety. A review of a handwritten statement signed by the Receptionist on duty on 12/12/2024, revealed the following: I don't know what happened, I do not remember seeing or letting [them] out nor did I hear any alarms going off that night. A review of a handwritten statement signed by the primary nurse (RN #1) dated 12/12/2024, revealed that at 09:30 PM, I was informed that [resident's name] was missing, and cannot find them admitted [to hospital with]: hypothermia and elevated WBC. A handwritten statement signed by the DON indicated that on 12/12/2024 at 10:00 PM, I received a call from the 02:00 PM-10:00 PM supervisor that the resident was missing and could not be located at the facility . A review of a handwritten statement dated 12/13/2024 at 12:12 PM, signed by the DON as having phone conversation with CNA #3, revealed that CNA #3 stated that at approximately 05:00 PM-06:00 PM, he observed the resident in the dining room sitting. At approximately 08:00 PM-09:00 PM, CNA #3 went to check the resident in their room, and he observed the resident's dinner tray was not touched. At 09:30 PM, CNA #3 initiated a search for the resident, and then informed the nurse and the Nursing Supervisor. During an interview with the survey team on 01/30/2025 at 01:17 PM, the Licensed Nursing Home Administrator (LNHA), DON, and the [NAME] President of Clinical Services (VPCS) revealed the following information: The DON confirmed Resident #160 eloped on 12/12/2024, that during the evening shift, the resident was last seen at 05:30 PM in the dining room. The DON stated staff realized between 08:00 PM-09:00 PM, the resident was not in their room, and staff made a facility-wide announcement to alert staff to search the whole facility for Resident #160. The DON confirmed the resident was not found in the facility during the search. The DON confirmed Resident #160 was an elopement risk; their picture was in the lobby; the resident had a wander guard; they were on the risk for elopement list at the front desk; and it was included in their ICCP. The DON stated the facility checked the resident's wander guard every shift for placement and function and that the facility had a wander guard tester that the nurse was responsible for using. The DON acknowledged that the last time the resident's wander guard was checked on 12/12/2024, was at at 06:00 AM. (This contradicted the MAR which was signed as checked on 12/12/2024 at 02:00 PM) The DON stated when the resident was missing, the Nursing Supervisor called the DON who then notified all the department heads and the regional staff. The LNHA stated we (management team) did another sweep of the building and the outside perimeter, and we were unable to locate Resident #160 so we called the police who arrived at the facility and searched both inside and outside. The LNHA continued that the police took a piece of Resident #160's clothing from their room, and had a K-9 smell the clothing for the resident's scent and the K-9 searched outside for the resident. The LNHA stated the DOM went in his car to ask local businesses if they saw Resident #160, and the facility contacted the resident's emergency contact to see if they knew where the resident would go with no success. The LNHA stated the police then called for a blood hound dog and drone, and the drone located the resident on the property in the back left side to the corner of the fence line. The LNHA said that you can not get out of the fence back there; that there were trees and brush/bushes. The LNHA stated that you needed to go into the tree line to actually see the corner of the fence where the resident was located. The LNHA stated that a CNA who was familiar with the resident from a previous facility where Resident #160 had eloped from said the resident was found in the trees and that the facility should check there. The LNHA stated at that time, the facility informed the police of this because the facility was unable to check outside since the police instructed the facility to stay inside so their scents would not interfere with the K-9 search. The LNHA stated that the police located Resident #160 in the trees. The police called the ambulance who transported the resident to the hospital and the resident was admitted for two days for hypothermia and elevated WBC. When questioned how Resident #160 eloped from the building, the LNHA replied that the elevator doors opened if you had a wander guard, but the elevator would not move, it alarmed. The LNHA stated that the facility still did not know how Resident #160 left the second floor nursing unit because when the resident returned from the hospital, their wander guard was functioning. The LNHA stated that only the perimeter doors were alarmed for the wander guard, and the alarm was loud enough to be heard from the elevator at the nurse's station. The VPCS stated at the time of the incident, the nurses were busy administering medication and the CNAs were doing second incontinent care for the residents. The LNHA said We tried to watch the video, hard to see, but [the resident] went out the front door, which did not alarm. The LNHA stated the Receptionist was there until 08:00 PM, and we asked her if she saw Resident #160, but the Receptionist denied it. The LNHA stated they were able to tell on the video the time the resident left the building, but he did not recall the time, and when asked if it was after 08:00 PM, the LNHA could not recall. On 01/30/2025 at 02:23 PM, the surveyor requested to watch the video from 12/12/2024, and the LNHA said it only stores for 72 hours, and we couldn't tell what time [the resident] left. This contradicted the LNHA's previous statement that the facility was able to determine what time the resident eloped from the video, but he could not recall the time. During an interview with the surveyor on 01/30/2025 at 02:28 PM, CNA #2 stated that they cared for Resident #160 frequently, but they were not in the facility on 12/12/2024, when the resident eloped. CNA #2 stated the resident was aggressive regarding exit seeking behaviors and that they often verbalized wanting to leave. CNA #2 stated that Resident #160 felt like they did not belong here, so the resident packed their book bag up and sat at the nurse's station waiting to go home. CNA #2 stated that Resident #160 talked about leaving all the time; that they went on the elevator and the wander guard would go off and staff had to redirect the resident and distract them with things to do. During a telephone interview with Surveyor #5 on 1/30/2025 at 02:00 PM, the Receptionist said she worked at the facility on 12/12/2024, from 04:00 PM-08:00 PM, and she did not know what happened. The Receptionist denied seeing Resident #160 that night; that there were pictures of the residents at risk for elopement. The Receptionist denied hearing an alarm go off at the front door, and stated she was unfamiliar with the wander guard. On 01/30/2025 at 02:30 PM, two surveyors along with VPCS, walked the property to see where Resident #160 was located. The following observations and interviews occurred: The surveyors and VPCS walked left out of the building and toward the rear of the property. Behind the building there was an approx eight feet (8 ft) tall vinyl fence that ran the length of the property, and beyond the vinyl fence were additional grounds that were contained by a chain link fence. That additional area was approx 50 yards (yds) wide with an approx length of 150 yds. The night of the elopement, the VPCS stated that he (the VPCS) walked to the vinyl fence on the rear right side where an 8 ft section of vinyl fence was missing and looked around and stated it was very dark and the VPCS was unable to locate the resident. The VPCS stated there were bushes and small trees that made it harder to see, so he returned to the front of the building where he overheard a police officer say they may have located the resident, and the officers began running behind the building and the VPCS followed them. The VPCS stated it was December and the trees had their leaves and were much bulkier and made it harder to see the area. The resident had gone through the vinyl fence and into the retention basin area that was enclosed within a chain-link fence and was found on the left side of the perimeter against the chain link fence approx halfway down the fence approx 25 yards from the gate. The VPCS stated the administrative team were assuming the resident left the building out the front door, walked around the building to the right to the far-left corner of the property and through the vinyl fence. When the surveyors approached the vinyl fence, they observed that the gate which had a hinge latch that was not closed, and the gate appeared to be stuck open with an approximately one foot wide opening to pass through. At that time, the VPCS attempted to see if the gate would latch and was unable to do so and stated, I could make it close. When asked, the VPCS could not recall if the gate was opened the night the resident eloped. The area behind the gate enclosed in the chain link fence had tall grasses and bushes and trees that sloped down into a valley in the middle similar to a retention basin with black rocks in the middle. The area sloped down sharply toward the middle and was uneven with thorn bushes and brambles. The VPCS stated that he believed the resident was found wearing shoes, gray sweatpants, and a white t-shirt. The VPCS stated the resident was found halfway down the fence line possibly 50 yards beyond the gate entrance along the fence line that was approx 100 ft deep. The VPCS stated the resident was alert and responsive. When asked if the resident had scratches on their skin when found, and the VPCS stated that he did not do a skin assessment at the time because the police were in charge of the situation, and the facility was told to step away. The surveyor observed the closest exit door from the facility to that area was from the First-floor rehabilitation unit that connected to a sidewalk that led to the area the resident was found. The VPCS stated that door was ruled out as where the resident eloped since no one reported hearing an alarm, and the VPCS confirmed if the resident left through the main entrance, the wander guard alarm would have sounded. During a telephone interview with Surveyor #3 on 01/31/2025 at 10:32 AM, RN #1 said that she recalled the incident, but she could not recall the exact dates and times. RN #1 said she believed that she was the supervisor that evening. At that time, the Surveyor confirmed with RN #1 that the Nursing Note was written by her on 12/12/24 at 07:40 PM, that indicated Resident #160 was not in their room to receive medication. RN #1 stated that she covered the medication cart as needed, and when the surveyor questioned what RN #1 did after she identified Resident #160 was not in their room, RN #1 stated she continued to administer medication to other residents. RN #1 stated she recalled seeing Resident #160 at the nurse's station around dinner time at maybe 06:00 PM. RN #1 recalled Resident #160 was pleasant and smiling with no indication they were exit seeking. RN #1 also recalled seeing Resident #160 in the dayroom, but she could not recall the time. RN #1 stated that a CNA (CNA #3) informed her that the resident's dinner plate was untouched as he was collecting trays (unable to recall exact time), and we started searching and I immediately notified the staff and called the DON. RN #1 stated the police were called and the inside and outside of the building was searched. The surveyor asked if RN #1 recalled seeing the resident's meal tray when they attempted to administer medications, and she responded, no, that the resident often refused their meal and would eat it later. Surveyor #3 asked RN #1 if they made additional attempts to administer Resident #160's medications, and the RN stated that typically if a resident was not in their room for medication, she looked for them or she went back to give them medication. RN #1 stated that CNA #3 had alerted her about Resident #160 shortly after. RN #1 confirmed Resident #160 wore a wander guard that was tested daily. During an interview with Surveyor #1 on 01/31/2025 at 11:17 AM, the DOM was asked if the stairways were alarmed, and the DOM confirmed they were alarmed including for a wander guard. The DOM stated that the therapy doors to the outside had a wander guard alarm, magnetic lock and were on a keypad. The DOM said there was no problem with the wander guard system at the time the resident eloped. The acceptable Removal Plan on 01/31/2025 at 01:16 PM, indicated the action the facility took to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: staff initiated the elopement protocol and contacted the police; Resident #160 was located outside the facility, assessed, and transported to the hospital for evaluation; Resident #160's plan of care was updated to include 1:1 supervision; Resident #160's wander guard was checked for function; the facility's wander guard system was checked for function; and all staff were educated on the facility's elopement protocol. The facility self-corrected the deficient practice and it was determined that the IJ was Past Non-Compliance (PNC); that the facility corrected their non-compliance on 12/30/2024. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 01/31/2025. NJAC 8:39-27.1(a)

Based on observation and interview, it was determined that the facility failed to ensure that the residents' leisure experience was provided in a manner to promote the dignity and respect of the residents, a) who were seated in the dayroom where a television program broadcast contained profanity and vulgar language was observed for 1 of 2 dining rooms, first floor, b.) the facility failed to maintain Resident dignity when staff were observed standing while feeding Residents their meals on 3 of 3 dining rooms observed for dining and c.) did not serve all residents seated at the same table at the same time for 1 of 3 dining areas, 2nd floor. This deficient practice was evidenced by the following: During the initial tour of the facility on 01/27/2025 at 7:15 PM, Surveyor #1 entered the first-floor dayroom. There were four residents and one staff member in the room. For entertainment the staff had the television playing. The surveyor observed on the television was a comedian using curse words and racial slurs repeatedly. At 7:19 PM, Surveyor #1 approached the Registered Nurse (RN) Supervisor who was seated at the nurse's station. Together they returned to the first-floor dining room where the program was still playing. The RN Supervisor acknowledged the profanity and stated the activities staff usually put the television on in the dining room for the residents. The RN supervisor stated the staff in the room should have changed the program to something more appropriate. At 7:24 PM, Surveyor #1 interviewed the Certified Nursing Assistant (CNA #1) who was present in the dining room. CNA #1 stated she had not heard the cursing or the slurs because she was concentrating on the residents she was seated with. CNA #1 further stated that language would be inappropriate, and the television station should have been changed. During an interview with Surveyor #1 on 01/29/2025 at 12:20 PM, the Director of Nursing (DON) stated the activities staff had a schedule for daily entertainment. Usually when there was no activity going on the staff would put the television on instead. The DON added that a CNA would remain in the room with the residents for safety and interaction. The television program should be something that can be viewed by a general audience. The DON confirmed the program the surveyor described with foul language and racial slurs would not be appropriate and the channel should have been changed. 49712 On 01/28/2025 at 12:09 PM, in the first-floor main dining room, a surveyor observed CNA #1 and a Certified Home Health Aide for a Hospice company, standing while each were feeding a resident at the same table, during the lunch meal. On 01/28/2025 at 12:09 PM, in the second-floor main dining room, surveyor #2 observed CNA #2 standing next to a resident assisting with feeding, during the lunch meal. On 01/28/2025 at 12:16 PM in the second-floor main dining room surveyor #2 observed the Quality Assurance Director (QAD) standing while feeding a resident. During an interview with surveyor #2 on 01/29/2025 the QAD said the expectation when assisting residents with feeding is to sit facing the resident. The QAD also said she should have pulled up a chair to feed the resident instead of standing. During an interview with Surveyor #2 on 01/29/2025 at 04:12 PM, the Licensed Nursing Home Administer (LNHA) said that staff should be sitting at eye level with the resident when assisting with feeding, for the dignity of the resident. 51232 On 01/28/2025 at 11:53 AM, Surveyor #3 observed seven residents who required assistance to consume their meals seated at the same table in the feeding dining room on the 2nd floor during lunch. Two facility staff members were stationed in the area to assist. Three residents received their meals and started eating, while the other four residents at the table did not receive their meals until 12:10 PM. On 01/28/2025 at 12:11 PM, Surveyor #3 observed Licensed Practical Nurse (LPN #5) in the feeding dining room on the 2nd floor during lunch, assisting a resident with their meal while standing over her/him. On 01/28/2025 at 12:15 PM, Surveyor #3 observed CNA #4 and LPN #5 feeding residents in the feeding dining room on the 2nd floor during lunch. Both staff members had their hair styled in braids, which touched several residents' food items multiple times as they brushed their hair away from their faces without performing hand hygiene. On 01/29/2025 at 12:04 PM, Surveyor #3 observed six residents who required assistance to consume their meals seated at the same table in the feeding dining room on the 2nd floor during lunch. Two facility staff members were stationed in the area to assist. Two residents received their meals and started eating, while the other four residents did not receive their lunch until 12:25 PM. On 01/29/2025 at 12:08 PM, Surveyor #3 observed CNA #5 in the feeding dining room on the 2nd floor during lunch. CNA #5 uncovered a resident's meal, set it up, removed the meal from the tray, and began feeding the resident at 12:08 PM. However, CNA #5 stopped feeding the resident to put clothing protectors on other residents, leaving the resident's food uncovered for eight minutes. CNA #5 resumed feeding the resident at 12:16 PM, but did not engage with the resident during the meal. She interrupted the feeding again to inform another staff member that she needed to go to the bathroom. CNA #5 then stood up, left the dining room, leaving the resident's food uncovered, and returned two minutes later to resume feeding the resident. On 01/29/2025 at 12:28 PM, Surveyor #3 observed a resident sitting in a geriatric chair (a large, padded chair designed to assist those with limited mobility) in the corner of the feeding dining room on the 2nd floor during lunch, with a bedside table placed over it. CNA #5 uncovered the resident's meal, set it up and removed the food from the tray at 12:28 PM, but no one began feeding the resident until 12:42 PM. During an interview with Surveyor #3 on 01/29/2025 at 12:26 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM #1), said that once residents' food is set up and uncovered, it should be fed to the residents immediately, as food should not be left uncovered due to infection control. During an interview with Surveyor #3 on 01/29/2025 at 12:52 PM, the Quality Assurance Director and Staff Educator (QAD/SE) said that once residents' food is set up and uncovered, it should be served to them immediately, as leaving food uncovered poses infection control risks. During an interview with Surveyor #3 on 01/31/2025 at 11:45 AM, the LNHA emphasized the importance of creating a home-like environment in the dining area. He said that meals should be served by removing them from trays, with all residents at a table being served simultaneously. He noted that staff members' hair should not come into contact with residents or their food while feeding, and that hand hygiene should be performed if staff touch their hair due to infection control concerns. Additionally, he highlighted the need for staff to actively engage with residents during mealtimes. He also mentioned that food should be covered to prevent infection and should not be left out for extended periods, as this could cause it to become cold. A review of a facility policy dated 05/01/2024, titled, Dining Policy, revealed, Resident Rights: Preferences, cultural needs, and dignity are respected. NJAC 8:39-4.1(a)(12)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a homelike environment by serving meals on trays on 1 of 2 floors (2nd floor). This deficient practice was evidenced by the following: On 01/28/2025 at 11:53 AM, Surveyor #1 observed Certified Nursing Assistant (CNA #4) in the feeding dining room on the 2nd floor during lunch, feeding a resident their meal without removing the food items from the meal tray. On 01/28/2025 at 11:54 AM, Surveyor #1 observed a facility staff member in the feeding dining room on the 2nd floor during lunch bringing in a meal tray for a resident and began feeding the resident without removing the food items from the tray. The Quality Assurance Director and Staff Educator (QAD/SE) entered the dining room and intervened, instructing the staff member to remove the food items from the tray while feeding the resident. On 01/29/2025 at 12:26 PM, Surveyor #2 observed CNA #5 in the feeding dining room on the 2nd floor during lunch, uncovering a resident's meal, setting it up, and serving it on the meal tray without inquiring about the resident's preferences. During an interview with Surveyor #1 on 01/31/2025 at 11:45 AM, the Licensed Nursing Home Administrator (LNHA) emphasized the importance of creating a home-like environment in the dining area. He said that meals should be served by removing them from trays. A review of a facility policy dated 05/01/2024, titled, Dining Policy, revealed, Resident Rights: Preferences, cultural needs, and dignity are respected. Dining Environment: Clean, comfortable, and promotes resident independence. NJAC 8:39-31.3(a)

Refer to F 689 C/O # NJ 182995 Based on interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to report and submit the facility investigation to the New Jersey Department of Health (NJDOH) within 5 days, specifically when a resident eloped for 1 of 3 residents reviewed for elopement (Resident #160). This deficient practice was evidenced by the following: A review of the EMR on 01/30/2025 at 2:20 PM revealed the following: According to the Admission Record Resident #160 was admitted with diagnoses including but not limited to: unspecified Dementia. A review of the most recent comprehensive Minimum Data Set (MDS) an assessment tool dated 09/26/2024 revealed Resident #160 had a Brief Interview for Mental Status (BIMS) score of 4/14 indicating Resident #160 was cognitively impaired. A further review of the MDS indicated the resident was independently ambulatory with no assistive device and used a wander/elopement alarm daily. A review of the Order Summary Report revealed a physician order dated 06/23/2024, for Wander guard on right ankle check placement and function every shift. A review of the Medication Administration Record (MAR) dated 12/1/2024-12/31/2024 revealed the aforementioned physician order for the wander guard. A further review of the MAR indicated that the wander guard for Resident #160 was signed as having been checked for placement and function on 12/12/24 at 6AM and 2 PM. A review of an Elopement Evaluation dated 09/26/2024 revealed a score of 5 and the following statements were checked; 2. Does Resident have a history of elopement or attempted leaving the facility without informing staff?, 4. Resident wanders, 6. Resident wanders aimlessly or non-goal directed, 7. Wander behavior likely to effect the safety or well-being of self/others, and 8. the resident's wandering behavior likely to effect the privacy of others. It was noted that 10. The evaluation indicated that score of 1 or higher indicates risk of elopement was not checked. A review of Resident #160's care plan revealed a Focus area of Risk for Wandering/Elopement. Under the Goal section; the resident will not leave the facility unattended. Under the Interventions section; Engaged Resident in purposeful activity with date initiated of 10/03/2024, Provide Care in Calm and reassuring manner with date initiated 10/03/2024, Provide clear simple instructions with date initiated 10/03/2024, Wander guard bracelet as ordered to right ankle and left ankle check placement and function as ordered with date initiated 10/03/2024. A review of the facility Investigation and Summary and Conclusion dated 12/17/2024 revealed the following: Under the background section Resident has a history of wandering aimlessly and exit seeking for which interventions have been put into place. Resident wears a wander guard to right ankle. Under the timeline of Events 12/12/2024 included but not limited to: .12/13/2024 Approx 2:00 am Department of Health called to report on event. During an interview on 01/30/2025 at 01:17 PM, the Licensed Nursing Home Administrator (LNHA) said Yes, we notified the DOH. On 01/30/2025 at 02:03 PM, the surveyor spoke with a Supervisor of Inspections at NJDOH, who said there was evidence of the facility calling DOH hotline but only left name, facility name and phone number. On 01/30/2025 at 04:31 PM, Director of Nursing (DON) provided a copy of sent email for reporting purposes, but it was to the Ombudsman not NJDOH. The LNHA said he will search in sent emails for the notification to the NJDOH. During a follow up interview with the surveyor on 01/31/2025 at 11:29 AM, the LNHA, DON were again asked was this reported as you said email was sent. The LNHA said we can't find the email that the AAS 45 was sent to DOH, but I have a record of the call and we did not receive callback from DOH. When asked why you had not called again, and the LNHA replied, at that time I did not think to call again. During a post survey telephone interview on 02/03/25 10:19 AM the DON was asked who is responsible to submit the AAS 45 and facility investigation to the department of health. The DON replied It's between me and the ADM (LNHA). When asked is there a timeframe for when this is to be completed and submitted to the NJDOH, the DON replied when the investigation is done, within 72 hours. We call it in then we usually wait for the DOH to call us back and tell us what else we need. A review of a facility policy titled Reporting Accidents and Incidents dated 05/01/2024 revealed under the Intent section: It is the policy of the facility to report Accidents and Incidents in accordance to State and Federal Regulations. Under the response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: .Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident . NJAC 8:39-5.1(a)

Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protection Notification, (Resident #1 and Resident #27). This deficient practice was evidenced by the following: On 01/28/2025 at 01:25 PM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #1 and Resident #27 as follows; 1.The SNFBPNR indicated Resident # 1 last covered Medicare day was 10/15/2024 and Resident # 1 remained in the facility. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was not given to Resident #1. Under 1. Was a SNFABN, Form CMS-10055 provided to the resident? No was checked. If no explain why the form was not provided: was hand written Resident remained in the facility is Medicaid pending. 2. The SNFBPNR indicated Resident #27 last covered Medicare day was 11/11/2024 and Resident #27 remained in the facility. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was not given to Resident #27. Under 1. Was a SNFABN, Form CMS-10055 provided to the resident? No was checked. If no explain why the form was not provided: was hand written Resident remained in the facility. During an interview with the surveyor on 01/29/2025 at 10:32 AM, the Social Worker (SW) was asked what SNFBPN were provided to a resident who is discharged home. The SW replied We give them Medicare A NOMNC (Notice of Medicare non-coverage CMS-10123). We provide copies of the forms to the resident. The surveyor then questioned what forms are required to be provided to a resident who the facility initiated discharge from Medicare A services and remained in the facility. The SW replied we give them the SNFABN and NOMNC form because they are staying in house. We issue them 2 days before the last covered day to give them an opportunity to appeal. On 01/29/2025 at 10:46 AM, the SW confirmed the 2 resident who stayed in facility after being cut from Medicare A should have received SNFABN and NOMNC. NJAC 8:39-4.1(a)(7)

C/O # NJ 177719, 180562 Based on observation, interview, and review of the Electronic Medical Record (EMR), and review of other facility documentation, it was determined that the facility failed to a.) ensure medications were administered in accordance with a physician's orders, b.) failed to follow physician order specifically for obtaining a urine culture, and c.) ensure physician's medication order was transcribed accurately. This deficient practice was identified for 3 of 32 sampled residents (Resident # 311, Resident #312, and Resident #414). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of 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.) Surveyor #1 reviewed the closed medical record on 01/29/2025 at 10:41 AM for Resident #312 as follows: A review of the Admission Record reflected the resident was admitted to the facility with diagnoses which included aftercare following joint replacement surgery, major depressive disorder, and muscle weakness. A review of the most recent Minimum Data Set (MDS), an assessment tool dated 11/25/24, reflected a brief interview for mental status (BIMS) score of 15/15, which indicated a fully intact cognition. A further review reflected the resident had received opioids (pain relievers) in the last seven days. A review of the individualized person-centered care plan reflected a focus area initiated 11/24/24, for alteration in pain or discomfort r/t (related to) arthritis, depression, osteoporosis, postoperative R THR (right total hip replacement). Interventions included assess for pain prior to beginning therapy program. Offer/administer PRN (as needed) analgesics (pain reliever) as ordered/indicated and monitor effectiveness. A review of the Order Recap Report (ORR) included the following a physician's orders (PO) Tramadol HCL oral tablet 50 mg (milligram) give 1 (one) tablet by mouth every 4 hours as needed for pain- mild 1-3 of 10, dated 11/23/24 Hydrocodone-Acetaminophen oral tablet 5-325 mg give 1 (one) tablet by mouth every 4 (four) hours as needed for pain- moderate 4-6 of 10, dated 11/23/24 A review of the corresponding November 2024 Medication Administration Record (MAR) revealed the resident received Tramadol on 11/23/24 at 9:42 PM, 11/24/24 at 12:01 AM, 11/24/24 at 7:30 AM and 11/25/24 at 7:40 AM documented as effective each time. A further review of the MAR revealed the resident received Hydrocodone-Acetaminophen on 11/24/24 at 12:41 PM documented as effective. A review of the facility automated medication dispensing machine Inventory on Hand report revealed the facility's machine stocked Tramadol 50 mg tablets but did not stock Hydrocodone-Acetaminophen. A review of the resident's Nursing Progress Notes for November 2024 did not reveal the Licensed Practical Nurse (LPN) had contacted the physician for a change in medication for moderate pain. On 01/28/2025 at 11:01 AM, the Licensed Nursing Home Administrator (LNHA) provided a Resident/Family Concern Form dated 11/25/24 which revealed . resident #312 verbalized he/she wanted to leave the facility against medical advice. Resident #312 verbalized he/she was not satisfied because their medication was not given in a timely manner. During an interview with Surveyor #1 on 01/29/2025 at 11:34 AM, the Director of Nursing (DON) stated Hydrocodone/Acetaminophen was not stocked in the facility automated dispensing machine. Surveyor #1 then requested from the DON the signed pharmacy packing slip receipt for the resident's Hydrocodone/Acetaminophen which would indicate when the medication had arrived at the facility. On 1/30/25 at 9:40 AM the DON and the Regional [NAME] President of Clinical Services (VPCS) requested to speak with the surveyor and in front of the survey team stated they had looked for the pharmacy packing slip and could not find a copy. VPCS stated he then called the pharmacy to ask for a copy of the signed packing slip. After speaking with the pharmacy it seems the medication was not delivered to the facility, he believed it was because the resident had been admitted late on a Friday night and the pharmacy required a written physical prescription before it would fill and deliver narcotic medications. The VPCS stated the nurse should have called the physician and made them aware the medication was not available and requested another medication for that moderate pain scale. A review of the facility's Pain Management Program policy dated 5/1/24, included . the facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental and psychosocial well-being . If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified . 34423 2.) A review of Resident #311 EMR on 01/28/2025 at 10:17 AM revealed the following; According to the Admission Record, Resident #311 was admitted to the facility with diagnoses incluidng but not limited to: Obstruction of the bile duct, and Urinary Tract infection (UTI). A review of the most recent comprehensive MDS dated [DATE] revealed a BIMS score of 12/15 indicating Resident #311 was cognitively intact. The MDS further indicated the resident was incontinent of bowel and bladder (having no or insufficient voluntary control over urination or defecation). A review of the OSR with active. completed and discontinued orders included a physician order dated 09/22/24 URINALYSIS AND CULTURE one time only related to Urinary tract infection. A review of the Results tab in the EMR did not include results for the Urine culture. A review of the Progress notes dated 9/23/2024 timed at 04:07 AM signed by the nurse . Urine analysis picked up by lab tech during previous shift on 9/22/24, 2-10 shift. A progress note dated 9/25/2024 timed at 4:25 PM, signed by the provider, Member seen today for follow up 2/2 leukocytosis (WBC 37), decreased PO (oral) intake. Provider RN contacted lab, U/A C&S (urine culture and sensitivity) was not sent as ordered on 9/23. During an interview with Surveyor #2 on 01/29/2025 at 11:44 AM, LPN #1 was asked what is the process when lab work is ordered by the physician. LPN #1 responded I put the order in EMR under new then laboratory then it takes you to lab so we can directly order the lab. Surveyor #2 asked what is the process for when a urine specimen is ordered. LPN #1 said it is the same process when blood work or specimen. We print the requisition and they also have the order on their app (application) on their phone. The requisition goes into the lab book. The nurse will collect the urine in AM. On the routine results if there was a problem it would be documented on the sheet for a new specimen to be sent. On 01/31/2025 at 08:45 AM, Surveyor #2 requested urine culture results from the VPCS. On 01/31/2025 at 11:35 AM, the VPCS told Surveyor #2 I can't find results. During an interview with Surveyor #2 on 01/31/2025 at 12:14 PM, the DON was asked what is the process when lab work is ordered by the physician. The DON replied put the order in EMR and goes directly via computer to the lab. The DON was questioned what is the process for when a urine specimen is ordered. The DON replied the same thing and if lost need to get another order and obtain the culture. The NP (Nurse Practioner) followed up in her note and spoke with the nurse who said the urine was not sent on day it was ordered. The DON confirmed the urine should have been sent on day it was ordered. The facility was unable to provide a policy regarding lab work. 51337 3.) A review of Resident #414's EMR on 01/28/2025, revealed the following: According to the Admission Record, Resident #414 was admitted to the facility with diagnoses including but not limited to: Unspecified Dementia (loss of cognitive function) and Essential Hypertension. A review of the most recent MDS dated [DATE] revealed a BIMS score of 07/15 indicating Resident #414 had moderately impaired cognition. A review of the Pharmacy Consultant Review of medications revealed a recommendation on 01/23/2025 for an order clarification of Quetiapine 25 mg BID (two times a day) because the Medication Discharge List from the hospital read Quetiapine 50 mg (milligrams) BID (twice a day). The review form was signed and dated by the Director of Nursing (DON) on 01/27/2025 at 09:00 AM. A review of the Electronic Medical Record (EMR) on 01/28/2025 on 01:54 PM revealed a Medication Discharge List from the hospital dated 01/16/2025, included Quetiapine 25 mg oral tablet (tab) 2 tab(s) Oral two times a day. A review of the Order Summary Report (OSR) dated with active orders as of 01/01/2025-01/31/2025 revealed that Quetiapine (medication that part of a treatment program to treat bipolar disorder and schizophrenia) 50 mg 1 tab PO (by mouth) at HS (bedtime) was entered in EMR by Licensed Practical Nurse/ Unit manager (LPN/UM #1) upon Resident #414's admission to the facility. A review of the Medication Administration Record (MAR) revealed that the dose of Quetiapine 25 mg 2 tabs PO BID as per the list of hospital discharged medications upon admission to the facility, was not administered Resident #414 until 1/28/2025 at 08:00 AM. During an interview with Surveyor #3 on 01/29/2025 at 09:34 AM, Registered Nurse/ Unit Manager (RN/UM #1) described how orders were transcribed during admission. RN/UM #1 stated that that they received a report from the hospital to confirm orders. She said supervisors put in the orders and the night shift would do reconciliation of orders. In the morning, the unit manager or the DON would check the admission orders. The DON would get an email from EPIC (Electronic Pharmacist Information Consultant) for review of admission orders. Our pharmacy is linked to EPIC. During an interview with Surveyor #3 on 01/29/2025 at 11:05 AM, Licensed Practical Nurse/ Unit Manager (LPN/UM #1) stated that they would compare the discharge summaries from the hospital that resident came with and the orders in the admission packet medication list. LPN/UM #1 stated that they matched the orders before transcribing into the EMR. LPN/UM #1 further stated that there was a 24-hour turnaround for EPIC's review. When asked about the Quetiapine admission order for Resident #414, LPN/UM #1 acknowledged that there was a medication error during the transcription of medications as the transcibed orders did not match hospital medications. On 01/29/2025 at 12:05 PM, during an interview with Surveyors #1 and #3, the DON stated that LPN/UM #1 transcribed an order on Quetiapine for a different patient. During an interview with the survey team on 01/31/2025 at 12:15 PM, the DON was asked how they ensure that the transcription of orders for admission was accurate. The DON stated that the supervisor put in the medications which would be reviewed for reconciliation by the nurse on 11-7 shift. DON further stated that EPIC is integrated with the EMR and that when they receive an EPIC review, they would immediately respond on the same day. A review of the facility provided policy titled Admission Orders dated 05/01/2024, included under Procedure 2. The admitting nurse will call the attending physician and clarify all orders on admission. 3. The admitting orders will be transcribed to the admission Physician Order Sheets (POS) once the orders are clarified or entered into the facility electronic medical record. NJAC 8:39 - NJAC-8:39-27.1(a), 29.3 (a) (6)

Based on observation, interview, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 01/29/2024 at 09:23 AM during a tour of the second-floor pantry the surveyor observed no thermometer in the freezer. There were 5 plastic containers of food in the freezer. The temperature log was marked with NA for the whole month of January. During that same tour the surveyor observed a paper wrapped sandwich labeled with a resident's room number and dated for 01/25/2025 in the refrigerator. During an interview on 01/29/2025 with the surveyor, the Quality Assurance Director (QAD) said that night shift nursing staff were responsible for the cleaning the refrigerator and checking the temperature. The QAD said she was not sure how long food was allowed to be in the refrigerator and she would have to check the policy. The QAD also said that she didn't think the freezer needed a thermometer unless there was food in there. During an interview on 01/30/2025 at 04:12 PM with the surveyor, the Licensed Nursing Home Administrator (LNHA) said per our policy there should have been a thermometer in the freezer. The LNHA also said that food brought in the facility should only be in the refrigerator for 72 hours and that sandwich should have been thrown out. A review of a facility provided policy dated 05/01/204, titled Food Handling- Refrigerators revealed under Procedures that, 6. Temperatures of refrigerators and freezers will be monitored daily and documented. A review of a facility provide policy dated 05/01/2025, titled Food Brought by Family and Visitors revealed that, All foods belonging to residents must be labeled with the resident's name, the item, and the use by date. Foods that are not labeled with use by date will be dated upon receipt and discarded within three days. Foods brought from home without an expiration date will be discarded after 3 days. N.J.A.C. 8:39-17.2(g)

Based on observation, interview, review of medical records, and review of other facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene practices for 3 of 3 staff observed during medication pass and lunch service, respectively b.) implement infection control measures for the handling and storage of respiratory equipment for 3 of 3 residents reviewed for respiratory care (Residents # 23, #315, and #413). This deficient practice was evidenced by the following: 1. On 01/28/2025 at 08:06 AM, Surveyor #1 observed Licensed Practical Nurse (LPN) #4 during medication pass. LPN#4 did not perform hand hygiene including not using Alcohol Based Hand Rub (ABHR) after administration of medications. On 01/28/2025 at 08:20 AM, Surveyor #1 observed LPN #4 administer medication to Resident #82. LPN #4 did not perform hand hygiene prior to administering the medications. During an interview with Surveyor #1 on 01/28/2025 at 08:27 AM, LPN #4 was asked about hand hygiene practices during medication pass. LPN #4 stated that she should have practiced hand hygiene before and after medication pass. LPN #4 further stated that they (staff) have received education about proper hand hygiene during medication pass. 2.) On 01/28/2025 at 12:09 PM, Surveyor #1 observed Certified Nursing Assistant (CNA) #1 assist Resident #414 in the 1st floor dining room during lunch service. CNA #1 opened a carton of fruit juice, poured the juice in a cup and helped the resident bring the cup to their mouth. After drinking, CNA #1 assisted Resident #414 with their meal. CNA # 1 did not offer nor assist Resident #1 to perform hand hygiene prior to eating. After assisting the resident, CNA #1 was observed to sanitize their hands with alcohol-based sanitizer. Surveyor #1 asked CNA #1 if prior to eating should the residents be offered an opportunity to perform hand hygiene. CNA #1 responded she should have wiped the resident's hands with the sanitizing wipes before helping the resident eat. 3.) On 01/28/2025 at 12:10 PM, Surveyor #1 observed a Hospice Aide (HA) assist Resident #68 in the 1st floor dining room during lunch meal. The HA did not offer nor assist Resident #68 to perform hand hygiene prior to eating. Surveyor #1 asked the HA together with CNA #1 the HA stated that they should have wiped the resident's hands with the sanitizing wipes before helping the residents eat. 4.) On 01/27/2025 at 06:33 PM, Surveyor #1 observed Resident #23's bagged nebulizer mask hanging low from the side table's handle with the entire bag touching the floor. At that time, Surveyor #1 interviewed LPN #6 and showed them the bag touching the floor. LPN #6 stated the bag should not be touching the floor. 5.) On 01/29/2025 at 01:10 PM, Surveyor #1 observed Resident #413 lying in bed. Resident #413's oxygen tubing was wrapped around the right-side rail with the tip of the nasal cannula touching the trash in the trash can located beside the bed. The oxygen concentrator (a medical device that extracts oxygen from the air and delivers it to a patient) was noted to be off. Surveyor #1 showed LPN #3 the nasal cannula. LPN #3 stated the nasal cannula should have been in the bag, pointing to a labeled plastic bag on the side table. LPN #3 took the oxygen tubing with the nasal cannula and said they were going to replace it. 49712 On 01/27/2025 at 06:44 PM, during the initial tour, Surveyor #2 observed Resident # 315 sitting in a wheelchair in his/her room with the nasal cannula laying on the floor not labeled. A review of Resident # 315's Admission Record revealed the resident was admitted to the facility with diagnoses including but not limited to: Acute Respiratory Failure with Hypoxia (low levels of oxygen in your body), Chronic Obstructive Pulmonary Disease (a group of lung conditions that cause breathing difficulties), and Vascular Dementia (type of dementia caused by brain damage from impaired blood flow). A review of Resident #315's Medication Administration Record (MAR) revealed a physician's order for oxygen at 3L (liters) per min via nasal cannula. A review of Resident #315's Treatment Administration Record (TAR) revealed a physician's order to change oxygen tubing if obstructed, compromised and damaged as needed every 24 hours as needed. There was no documentation that the oxygen tubing had been changed per the TAR. During an interview on 01/29/2025 at 12:36 PM with Surveyor #2, the Licensed Practical Nurse (LPN) # 2 said that she thinks oxygen tubing gets changed weekly on 3rd shift, and if gets dirty or drops on the floor. LPN #2 also said that the tubing should be labeled and dated when changed. When if there was documentation of oxygen tubing changes, LPN #2 said I am not sure maybe in a note. During an interview on 01/29/2025 at 12:56 PM with Surveyor #2, the Infection Preventionist (IP) said that oxygen tubing used to be changed on a weekly basis, now it is if compromised, on the floor, or damaged. Oxygen tubing should be dated and labeled and documented in the MAR when it is changed. When asked when Resident # 315's oxygen tubing was last changed the IP looked in the MAR and replied, I don't know it wasn't documented. During an interview on 01/30/2025 at 04:12 PM with Surveyor #2 the Director of Nursing (DON) said that Resident #315 is known for taking the oxygen off and they always find it on the floor. The DON said that the oxygen tubing should be changed for infection control when found on the floor and documented in the MAR or TAR. A review of the facility on 01/28/2025 at 10:14 AM, titled Hand Hygiene Policy dated 04/01/2024, did not include hand hygiene before and after medication pass. A further review of the policy indicated under Procedure: 3. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed .d. Before and after assisting a resident with meal. A review of a facility provided policy on Respiratory Equipment dated 05/01/2024 under section Procedure and Routine Schedule Changes revealed 3. Statement . Nebulizer masks are stored in a plastic bag when not in use, or as per resident's preference. 9. Statement . Nasal cannulas are stored in a plastic bag when not in use, or as per resident's preference, Nasal cannulas changed when damaged, visibly soiled and PRN . 8:39-19.4 (k)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to a) maintain professional standards of clinical practice by not following the physician's order for blood pressure (BP) parameters for 1 of 28 sampled residents (Resident # 29) and b) follow professional standards of nursing practices and facility policy by not notifying the Licensed Independent Practitioner of a prescribed medication that was not administered as ordered for 1 of 2 residents during a medication pass observation. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45 Chapter 11, Nursing Board. The Nurse Practice Act for the State of New Jersey states; the practice of nursing as a Registered Professional Nurse is defined as diagnosing, and treating human response 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 restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized Physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. There was no adverse effect on Resident #29. According to the facility Admission Face Sheet Resident #29 was admitted to the facility with diagnoses including but not limited to: Cerebral Vascular Accident (stroke) and hypotension. A review of the physician's orders revealed an order dated 12/17/2022 for an anti-hypotensive medication; Midodrine HCI Oral Tablet 5 MG tablet, 1 tablet by mouth 3 times daily. Special Instructions: HOLD IF SYSTOLIC BLOOD PRESSURE (SBP) IS greater than 120. Medical Conditions: Hypotension. On 03/27/2023 at 10:26 AM, Surveyor #1 reviewed the Consultant Pharmacist's Medication Regimen Reviews from the previous 6 months (9/2022-3/2023) that indicated that there were multiple instances when Midodrine was not held as per BP parameter. On 03/29/23 at 12:35 PM, the surveyor reviewed the Electronic Medication Administration Record (e-MAR) that showed the time of medication administration as well as the blood pressures at time of administration. The following information was obtained: A review of the March 2023 e-MAR reflected that Midodrine was held (not administered) on the following dates and times: On 03/12/2023 at 12:00 PM the SBP was 100. On 03/14/2023 at 08:00 AM the SBP was 111. On 03/20/2023 at 08:00 AM the SBP was 114. A review of the February 2023 e-MAR reflected that Midodrine was administered outside of the parameters (Hold for SBP greater than 120) as follows: On 02/7/2023 at 08:00 AM the SBP was 165 On 02/15/2023 at 08:00 AM the SBP was 127 On 02/16/2023 at 08:00 AM the SBP was 125 On 02/20/2023 at 08:00 AM the SBP was 122 On 02/12/2023 at 12:00 PM the SBP was 131 On 02/13/2023 at 12:00 PM the SBP was 130 On 02/15/2023 at 12:00 PM the SBP was 134 On 02/27/2023 at 12:00 PM the SBP was 134 On 02/1/2023 at 04:00 PM the SBP was 124 On 02/4/2023 at 04:00 PM the SBP was 137 On 02/12/2023 at 04:00 PM the SBP was 123 On 02/23/2023 at 04:00 PM the SBP was 121 On 02/25/2023 at 04:00 PM the SBP was 149 A review of the January 2023 e-MAR reflected that Midodrine was administered outside of the parameters (Hold for SBP greater than 120) as follows: On 01/5/2023 at 08:00 AM the SBP was 145 On 01/8/2023 at 08:00 AM the SBP was 143 On 01/16/2023 at 08:00 AM the SBP was 125 On 01/23/2023 at 08:00 AM the SBP was 128 On 01/2/2023 at 12:00 PM the SBP was 133 On 01/7/2023 at 12:00 PM the SBP was 158 On 01/28/2023 at 12:00 PM the SBP was 122 On 01/7/2023 at 04:00 PM the SBP was 158 On 01/28/2023 at 04:00 PM the SBP was 122 On 03/29/2023 at 08:41 AM, the surveyor interviewed the Interim Unit Manager (IUM) for the 2nd floor unit. The IUM stated that the process for administering medications requires the nurse to first check the physician order and follow it as directed. If the medication has a parameter such as a blood pressure (BP), the nurse must first check the residents current BP. Options on the e-MAR then prompt the nurse to document the blood pressure and chose if the medication was administered or not given (held). If the medication is administered, the nurse checks administered. If the medication is held an option to click not given is checked. The e-MAR will either reflect a check indicating that the medications was administered or an X indicating that the medication was not given. The surveyor then reviewed the Consultant Pharmacist's Medication Regimen Review for the month of February with the IUM. The report indicated that there were administration errors regarding the administration of Midodrine given outside of parameters. The report also stated that, the Assistant Director of Nursing (ADON) was notified. The IUM acknowledged that she was the previous ADON and that she remembered the report. On 03/31/2023 at 01:18 PM, the surveyor interviewed the [NAME] President of Clinical Services (VPCS) in the presence of the survey team. The surveyor reviewed the findings of the medication Midodrine being administered outside of the parameters and the VPCS acknowledged the concern stating, The resident could become hypertensive. A review of the facility's Medication Administration Policy and Procedure dated 3/1/2023, did not include documentation regarding medication parameters. NJAC 8:39-27.1(a) 40041 According to the Admission Record Resident #3 was admitted to the facility with a diagnosis that included but not limited to Hyperlidemia (high cholesterol). On 03/28/23 at 08:04 AM, Surveyor #2 conducted a medication pass observation for Resident #3. Licensed Practical Nurse (LPN #2) searched the medication cart then stated, its not here, referring to Cholestyramine 4 GM (gram) packet. LPN #2 proceeded to select the box indicating that the medication was not given. A review of Resident #3's Physician Order Form revealed an order for Cholestyramine 4 GM (grams) packet 1 packet By Mouth Twice daily (8:00 AM and 4:00 PM) Diagnosis Described: lower cholesterol with a start date of 10/31/2022. A review of the Medication Administration Record (MAR) revealed that the 08:00 AM dose of Cholestyramine was not administered on 03/28/2023 for the 8:00 AM dose. During an interview with Surveyor #2 on 03/30/2023 at 12:57 PM, Surveyor #2 asked LPN #1 what is your process when medications are not available in the medication cart during medication administration. LPN #1 replied, call the doctor for medications that are not available, sometimes the doctor Ok's for one dose not to be given, sometimes the doctor will recommend an alternative while the medication is not here yet. During an interview with Surveyor #2 on 04/03/2023 at 11:27 AM, the IUM confirmed that the 08:00 AM dose of Cholestyramine was not administered on 03/28/2023. In addition, the IUM replied, No when asked was the doctor notified that the medication was not administered. During an interview with Surveyor #2 on 03/31/2023 at 01:18 PM, Surveyor #2 asked when medications are not available at the designated time, what is your process. The VPCS stated the nurse should check the backup automated medication dispensing machine, and if it is not there they should call the physician, let the doctor know, and whatever orders the physician wants to give at that moment and call the pharmacy for a stat (rush) delivery. A review of a facility policy titled Medication administration- medication availability, dated 2/1/2023 revealed Our facility shall administer medications as per physician's order and protocol. Procedure: .4. In the event a medication is not available during medication administration, the licensed professional will proceed to check medication availability in the back up medication box. If medication is not available in the facility, the licensed professional will call the primary physician for further instructions. The pharmacy will be informed immediately. NJAC 8:39-27.1(a) NJAC 8:39-29.2(d)

Based on interview, record review, and review of other facility documentation, it was determined that the facility a)failed to ensure that the Consultant Pharmacist (CP) reported irregularities of drug regimen to the physician, and b.) failed to act upon the CP report of irregularities found while reviewing the drug regimen. This deficient practice was identified for 1 of 28 sampled residents, (Resident #29) and was evidenced by the following: There was no adverse effects to Resident #29. According to the Admission Face Sheet Resident #29 was admitted with diagnoses including but not limited to: Cerebral Vascular Accident (stroke) and hypotension. According to the March 2023 Physician Order Sheet, resident #29 had an order dated 12/17/2022 for an anti-hypotensive medication; Midodrine HCI Oral Tablet 5 MG (milligram) tablet, 1 tablet by mouth 3 times daily with Special Instructions, (parameter) to hold the medication when the Systolic Blood Pressure (SBP) (top number in BP) is greater than 120. On 03/27/2023 at 10:26 AM, the surveyor reviewed the Consultant Pharmacist's Medication Regimen Reviews (CPMRR) for the months of January 2023 through March 2023. For the month of January 2023, the Consultant Pharmacist did not identify or report Midodrine as being administered outside of parameters. A review of the February 2023 the Consultant Pharmacist reported; Midodrine ordered to be held if Systolic blood pressure greater than 120-on 2/1/23 at 4 pm, on 2/4/23 at 4 pm and on 2/7/23 at 8 AM Systolic blood pressure was greater than 120 but Midodrine was signed as administered. [nurses name] ADON was notified. The CPMRR created in March reported, Midodrine ordered to be held if Systolic Blood Pressure greater than 120. Multiple instances noted when medication was not held, 2/12 8 am and 12 noon; 2/13 12 pm; 2/15 8 am and noon; 2/16 8 am; 2/20 8 am; 2/23 4 pm; 2/25 4 pm; 2/28 8 am-[nurses name], DON was notified. On 03/29/2023 at 12:35 PM, the surveyor reviewed the January 2023, February 2023, and March 2023 Electronic Medical Record (EMR's) that included the Medication Administration Records (e-MAR's) which revealed the nurses administered the medication Midodrine HCI 5 MG to Resident #29 when the SBP was above 120, 22 times and held Midodrine HCI 5 MG, 3 times when the SBP was less than 120 as follows: A review of the March 2023 e-MAR reflected that Midodrine was held (not administered) on the following dates and times: On 03/12/23 at 12:00 PM the SBP was 100. On 03/14/23 at 08:00 AM the SBP was 111. On 03/20/23 at 08:00 AM the SBP was 114. A review of the February 2023 e-MAR reflected that Midodrine was administered outside of the parameters (Hold for SBP greater than 120) On 02/7/2023 at 08:00 AM the SBP was 165 On 02/15/2023 at 08:00 AM the SBP was 127 On 02/16/2023 at 08:00 AM the SBP was 125 On 02/20/2023 at 08:00 AM the SBP was 122 On 02/12/2023 at 12:00 PM the SBP was 131 On 02/13/2023 at 12:00 PM the SBP was 130 On 02/15/2023 at 12:00 PM the SBP was 134 On 02/27/2023 at 12:00 PM the SBP was 134 On 02/1/2023 at 04:00 PM the SBP was 124 On 02/4/2023 at 04:00 PM the SBP was 137 On 02/12/2023 at 04:00 PM the SBP was 123 On 02/23/2023 at 04:00 PM the SBP was 121 On 02/25/2023 at 04:00 PM the SBP was 149 A review of the January 2023 e-MAR reflected that Midodrine was administered outside of the parameters (Hold for SBP greater than 120) On 01/5/2023 at 08:00 AM the SBP was 145 On 01/8/2023 at 08:00 AM the SBP was 143 On 01/16/2023 at 08:00 AM the SBP was 125 On 01/23/2023 at 08:00 AM the SBP was 128 On 01/2/2023 at 12:00 PM the SBP was 133 On 01/7/2023 at 12:00 PM the SBP was 158 On 01/28/2023 at 12:00 PM the SBP was 122 On 01/7/2023 at 04:00 PM the SBP was 158 On 01/28/23 at 04:00 PM the SBP was 122 The facility was unable to provide documentation that the CPMRR regarding medication being given outside physician ordered parameters was addressed by the nursing staff. On 3/31/2023 at 1:18 PM, the surveyor interviewed the [NAME] President of Clinical Services (VPCS) in the presence of the survey team and the Licensed Nursing Home Administrator. The surveyor reviewed the findings of the medication Midodrine being administer outside of the parameters and the VPCS acknowledged concern stating, The resident could become hypertensive. A review of a facility policy titled, Pharmacy Services-Drug Regimen Review, dated 2/1/2023 included the following under #1. The drug regimen of each resident will be reviewed at least monthly by a licensed pharmacist and the pharmacist will report any irregularities to the attending physician, the facility's medical director and the director of nursing (DON). Under #4 and these reports will be acted upon. NJAC-8:39-29.3(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 03/21/2023 from 9:33 to 10:13 AM, the surveyor accompanied by the Director of Dietary (DOD), observed the following in the kitchen: 1. In the pot and pan drying rack area of the kitchen a stack of third pans on a middle shelf were in the inverted position and stacked upon each other. The surveyor removed the top third pan from the stack and observed a wet, watery substance on the outside of the pan below. The DOD stated, That's wet nesting. The DOD removed the third pans from the drying rack. Next to the third pans the surveyor removed a sixth pan from the top of approximately 6 pans that were inverted and stacked upon each other. The surveyor and DOD observed a wet and watery substance on the external surface of the pan below. The DOD removed the sixth pans from the drying rack 2. In the prep station area a cleaned and sanitized meat slicer was on the prep counter. The meat slicer was uncovered and exposed. The DOD agreed that the meat slicer was cleaned and sanitized and not in use at the time. The surveyor reviewed the facility policy with SUBJECT: WET NESTING OF KITCHEN WARES, dated 02/02/2023. The policy revealed the following under INTENT: Kitchen will wash, rinse, sanitize and air dry (when wet) all pots, pans, cook ware, service wares and small wares following each meal. Items will not be force dried with any type of rags or wipes. In addition, the following guidance was revealed under PROCEDURE: 1. When using dish machine. a) After items have been properly cleaned, rinsed, and sanitized and items are still wet staff will stack or angle pans in such a way on a designated clean air drying rack so they may completely dry prior to usage without any pooling or nesting water visible or touch. 2. When using pot and pan 3 compartment sinks. a). After items have been properly cleaned, rinsed, and sanitized, items will be stacked or angled in such a way on a designated clean air drying rack so they may completely dry prior to usage without any pooling or nesting water visible or touch. The facility did not provide a policy/procedure for storage of cleaned and sanitized food preparation equipment. NJAC 18:39-17.2 (g)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to develop a comprehensive, person-centered care plan for 3 of 28 sampled Residents, (Resident # 189, Resident #48, and Resident #135). This deficient practice was evidenced by the following: 1.) During the initial tour of the facility on 03/21/2023 at 10:54 AM, Resident # 189 was observed in bed with nasal oxygen at 2 liter/minute in use. Resident #189 said he/she does not use oxygen at home and has only used since being hospitalized . A review of the Admission Face Sheet revealed Resident #189 was admitted to the facility with diagnoses including but not limited to: Shortness of Breath. A review of the most recent Minimum Data Set (MDS) an assessment tool used to facilitate care, dated 3/16/2023 revealed under section C a Brief Interview for Mental Status score of 6/15, indicating Resident #189 had severe cognitive impairment. Under section O the MDS indicated Resident #189 used oxygen while a resident. A review of the Physician Orders as of 3/9/2023 revealed an order for nasal oxygen 2L(liters)/min (minute) change O2 tubing every Thursday A review of Resident #189's Care Plan did not include the use of oxygen. On 03/27/2023 at 09:39 AM, the surveyor reviewed Resident #189's care plan again and there was no care plan for oxygen use. During an interview with Surveyor #1 on 03/29/2023 at 09:23 AM, Unit Manager/Registered Nurse (UM/RN #1) said the admitting nurse, Unit Manger and MDS coordinator are responsible for doing the care plans. UM/RN #1 went on to say she expects pain management, pressure ulcer, ADL's (Activities of Daily Living), side rails, falls and if on antibiotic or has an infection, dialysis, and if on oxygen yes, there should be a care plan. UM/RN #1 further explained that the MDS coordinator is to add any special disease, such as if Diabetic and getting insulin, it has to be on the care plan. UM/RN #1 confirmed that if a resident is diabetic the surveyor would expect to see a care plan. UM/RN #1 said that oxygen and bipap (a device that helps with breathing) are done upon admission by the admitting nurse and we put an oxygen order in and it goes on baseline care plan. UM/RN #1 explained that she goes through the admission chart the next day and I do the comprehensive care plan and then the MDS coordinator goes in and adds anticoagulant, insulin if diabetic, dialysis and anything else that needs to be done. On 03/29/2023 at 09:29 AM, Surveyor #1 requested UM/RN #1 to look at Resident #189's care plan and tell the surveyor if oxygen use is care planned. On 03/29/2023 at 09:31 AM, UM/RN #1 said, No, Resident #189 doesn't a have care plan for oxygen. UM/RN #1 replied, Yes, when asked should he/she have a care plan for oxygen use. During an interview with Surveyor #1 on 03/31/2023 at 01:27 PM, the [NAME] President of Clinical Services (VPCS) said we have the unit manger or MDS coordinator do the care plans. We do the baseline care plan in 48 hours and comprehensive care plan as soon as possible, 72 hours to 7 days. When asked what is expected to be on a care plan, the VPCS replied, A picture of the patient. If they have a Foley, wounds, side rails, oxygen, bipap, smoking. 43936 2.) On 03/29/2023 at 11:11 AM, during the initial tour of the facility, Surveyor #2 observed Resident #48 awake in bed. At this time, Resident #48 confirmed he/she used insulin (medication used to manage sugar in the blood). A review of Resident #48's MDS dated [DATE] located in the Electronic Medical Record (EMR) revealed he/she had a diagnosis of but not limited to Diabetes Mellitus (disease involving elevated blood-glucose levels). The MDS further revealed that Resident #48 received insulin injections. A review of Resident #48's Physician's Orders revealed an order for Humalog 100 Unit/Milliliter (mL) and Insulin Glargine 10 units (medications used to manage blood-sugar) at bedtime. A review of Resident 48's Care Plans located in the EMR did not include a care plan for Diabetes Mellitus. On 03/28/2023 during an interview with Surveyor #2, UM/RN #1 confirmed that if a resident is diabetic and receives insulin they should have a diabetic care plan just to make sure they (facility) are monitoring what's going on. UM/RN #1 said, To make sure we check blood sugar with sliding scale prior to administering insulin when Surveyor #2 asked what interventions might be included in the care plan. On 03/31/2023 at 01:13 PM, during an interview with Surveyor #2, the VPCS said residents should have a care plan if they are diagnosed with Diabetes Mellitus. Further, the VPCS said that a care plan should be established within 72 hours. 3.) A review of Resident #135's closed record revealed that he/she passed away. A review of Resident #135's MDS dated [DATE], located in the EMR, revealed he/she had a diagnosis of Diabetes Mellitus (disease involving elevated blood-glucose levels). The MDS further revealed that Resident #135 received insulin injections. A review of Resident #135's Physician's Orders revealed orders for Novolog Flexpen (insulin medication used to manage sugar in the blood) On 03/28/2023 at 01:00 PM, during an interview with Surveyor #2, UM/RN #1 confirmed that Resident #135 never had a care plan for Diabetes Mellitus. On 03/31/2023 at 01:13 PM, during an interview with Surveyor #2, the VPCS said residents should have a care plan if they are diagnosed with Diabetes Mellitus. Further, the VPCS said that the care plan should be established within 72 hours. A review of a facility policy titled Comprehensive Resident Centered Care Plans, dated 3/01/2023, revealed that a person-centered care plan includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. A further review of the policy indicated under Procedure, that a person-centered care plan includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. NJAC 8:39-11.2 (e)

C# NJ CROSS REFERENCE F 309 Based on observation, interviews, review of medical records (MRs), and other facility documentation, it was determined that the facility failed to ensure that Care Plan (CP) problems, goals and approaches/interventions were consistently revised, updated and/or followed for 1 of 3 residents, (Resident #3). The CP for Resident # 3 regarding actual impaired skin integrity was not revised and/or updated in order to prevent the development of and/or promote the healing of Pressure Ulcers (PU) which resulted in a new Stage II PU. The facility's failure to follow and/or revise interventions on the CP to promote wound healing, for an existing sacral PU and a new Stage II PU, including but not limited to; physician ordered wound treatments and monitoring of the wound site, created an Immediate Jeopardy (IJ) situation for Resident #3. The facility Administrator and Director of Nursing (DON) were notified of the IJ on 8/17/2015 at 3:15 p.m., the first day of survey. The IJ which began on 8/7/2015, was lifted based on an acceptable plan of correction (POC) which was implemented on 8/17/2015 at 5 p.m. 1. See Example A, #1. The immediate jeopardy which began on 8/7/2015 and was identified on 8/17/2015, was lifted on 8/17/2015 as evidenced by the implementation of an acceptable plan of correction as follows; 1. The physician and/or Nurse Practitioner was notified and the treatment order was transcribed to the TAR and completed, CP was reviewed to address current modalities, a low air loss mattress was placed on the bed on 8/17/2015. 2. All resident treatment orders will be audited weekly beginning 8/17/2015 to assure all treatments are being administered per POs and Care Plans reviewed to ensure appropriate interventions are in place. 3. The DON will review all new treatment orders and corresponding TARS weekly to ensure all orders are being properly transcribed and administered. Inservices began for licensed nursing staff related to proper transcription and implementation of physician orders [REDACTED]. Inservices began for CNAs related to reporting skin concerns to the nursing staff when treatments are not present. New and re-admission orders [REDACTED]. New and re-admission orders [REDACTED]. 4. Weekly random audits will be completed by the DON on wound treatments and corresponding care plans to ensure they are done per physician orders [REDACTED]. NJAC 8:39-27.1(a)

Complaint #: NJ A. Based on observations, interviews and review of the medical records (MR) and other facility documentation, it was determined that the facility failed to provide the necessary care and services for 1 of 3 sampled residents (Resident #3) who was readmitted to the facility on [DATE] with a Sacral Pressure Ulcer (PU) measuring 2 centimeters (cm) by 1.8 cm. with tunneling, however, there was no documented measurement of the depth of the tunneling. A sacral wound treatment, ordered by the physician at readmission, on 8/7/2015, was not completed for 10 days, from 8/7 through 8/16 because it had not been transcribed to the 8/2015 Treatment Administration (TAR) until 8/17/2015, the first day of survey. On 8/17/2015, Resident #3 was observed by the surveyor without a Sacral PU dressing; the facility staff then reviewed the MR and the treatment was initiated. On 8/17/2015, 10 days after the initial physician order, the Sacral PU increased in size from 2 cm. by 1.8 cm. with no depth of tunneling measured and was assessed by the facility Registered Nurse Unit Manager (RN UM #1) as a Stage III, measuring 3 cm. by 3 cm. with 2 cm. tunneling. Additionally, the RN UM #1 noted a new Right (R) Lateral Sacral Stage II PU measuring 1.5 by 1.5 cm., and R and left (L) buttock excoriation measuring 11 cm. by 13 cm. For a period of 10 days, from 8/7/2015 through 8/16/2015, facility licensed nursing staff, on the 11-7 shift, conducted 24 hour chart checks on Resident #3's MR and did not note the discrepancy of the physician ordered Sacral PU treatment and the lack of the treatment documention on the TAR. For a period of 11 days, on 3 shifts, from 8/7/2015 through 8/17/2015, there was no documentation that Resident #3's care givers reported the Sacral PU to a supervisor. A skin assessment (SA) was signed/initialed as completed by a Registered Nurse (RN #3) on 8/10/2015, 3 days after admission, however, there was no documentation in the MR or on the SA regarding any of Resident #3's wounds including the Sacral PU. Additionally, the facility failed to administer and/or document physician ordered treatments for vascular leg ulcers for 1 of 3 sampled Residents (Resident #3). The facility's failure to provide the necessary care and services to promote wound healing and consistently and accurately conduct skin assessments, report any change in skin condition, implement pressure relieving devices, transcribe physician orders [REDACTED].#3. The facility Administrator and Director of Nursing (DON) were notified of the IJ on 8/17/2015 at 3:15 p.m., the first day of survey. The IJ which began on 8/7/2015, was lifted based on an acceptable plan of correction (POC) which was implemented on 8/17/2015 at 5 p.m. 1. According to the facility Admission face sheet, Resident #3 was admitted to the facility in 7/2015 with [DIAGNOSES REDACTED].A Minimum Data Set (MDS), an assessment tool, dated 7/27/2015, revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition and Resident #3 needed assistance with all activities of daily living (ADLs) and was admitted with two Stage II PUs. An Initial Care Plan (CP), dated 7/21/2015, did not include any indication that Resident #3 had and/or was at risk for PU or was receiving any treatments r/t a sacral PU or foot/leg ulcers. However, an undated Care Plan (CP), included that Resident #3 was at risk for skin breakdown related to (r/t) incontinence and had actual impaired skin, vascular ulcers and a Stage II PU of Sacrum with interventions which included but were not limited to; daily skin monitoring during care done by CNAs and notifying nurse of any areas of concern, weekly SA by nurse, pressure reducing mattress, wound care per physician orders [REDACTED]. An undated Nursing Admission/Readmission Assessment, verified by the Director of Nursing (DON) that it was completed on 7/20/2015 indicated that Resident #3 was admitted with a Stage II Sacral Wound measuring 2 centimeters (cm.).Nurses Notes (NN) indicated Resident #3 was transferred to the hospital for lower extremity active bleeding on 7/31/2015 and readmitted to the facility on [DATE].A Nursing Admission/Readmission Assessment for the Braden Scale, a PU risk assessment, dated 8/8/2015, revealed a score of 16, which indicated Resident #3 was at low risk for developing a PU. An undated Nursing Admission/Readmission Assessment, completed by the 3-11 shift Licensed Practical Nurse (LPN #3), was verified by nursing DON that it was completed on 8/7/2015. The assessment indicated that Resident #3 was readmitted with a Sacral Wound measuring 2 cm. by 1.8 cm. with tunneling, but there was no indication of the Stage of the wound or the depth of the tunneling. On readmission, a Physician order [REDACTED]. sacral wound, cleanse (with) Normal Saline Solution (NSS), apply Santyl to center of wound bed and cover with CDD (clean dry dressing) daily.2. R (Right) medial ankle wound, cleanse with NSS, apply Santyl to fill wound and cover with gauze daily.3. L (left) lower leg and medial malleadues, apply layer of Santyl over any yellow or moist areas, cover with no adherent gaze and CDD daily.4. L foot and heel apply xeroform gauze over and dry necrotic areas, cover with CDD daily.In addition, a skin assessment (SA) was ordered to be completed two times weekly using the following code: 1. Skin Intact, 2. Previous Problem Noted, 3. New Skin Problem. During a tour of the unit with the DON on 8/17/2015 at 9:55 a.m., Resident #3 was observed in bed, wearing a disposable brief. Resident #3 had a Foley Catheter (FC) in place. A PU was observed on the sacrum with no covering/dressing. The bed and floor were checked and no dressing was found. The surveyor asked the resident if a treatment was going to be completed and the resident stated he was not sure what was done back there. Resident #3 did not have a low air loss mattress. Additionally, Resident #3 had dressings/bandages to the R and L leg vascular ulcers which were not dated. Resident #3 stated that the facility staff have changed his leg bandages and thought they did it daily. During an interview with the surveyor on 8/17/2015 at approximetely 11:00 a.m., Resident #3's assigned 7-3 shift CNA #3 stated she had checked the resident at approximetely 7:30 a.m. and 9:30 a.m. but did not take the brief off or turn the resident over to check him as he had a FC. CNA #3 confirmed she was not aware and had not been informed that Resident #3 had a sacral wound. Review of the 8/2015 Treatment Administration Record (TAR) at 3 p.m. on 8/17/2015 by the surveyor, revealed the treatment for [REDACTED]. The TAR confirmed the PO, however, the treatment was not on the TAR from 8/7 through 8/16/2015, a total of 10 days. A 7-3 shift nurse initialed/signed the TAR for 8/17/2015 and indicated treatment done on 7-3 shift (8/17/2015) when noted. Additionally, the TAR confirmed the above POS for the lower leg extremity (LLE) treatments to be completed on the 3-11 shift, however, for a total of 3 wounds to be dressed daily from 8/7 through 8/16/2015, a total of 30 opportunities, the TAR was not initialed/signed as completed 24 times. There was no indication on the back of the TAR as to why the LLE treatments were not completed. During an interview by the surveyor on 8/17/2015 at approximetely 3:15 p.m., the DON stated that the staff had reviewed the MR and TAR for Resident #3 on 8/17/2015 after the resident was observed without a dressing and noted that the sacral wound treatment ordered on [DATE] had not been transcribed to the 8/2015 TAR. The DON stated she would follow up with an investigation to determine if the treatments had been done. During an observation by the surveyor, accompanied by the RN UM #1 on 8/17/2015 at 4 p.m., Resident #3's sacral area was observed and measured by the RN UM #1. The dressing had already been removed prior to the surveyor observation. The PU was noted by the RN UM #1 as a Stage III with slough measuring 3 cm. by 2 cm. with 2 cm. tunneling, which was an increase in size from the 8/7/2015 wound measurement of 2 cm. by 1.8 cm. with no depth of tunneling measured. A new Stage II, R lateral sacral wound was observed by the RN UM #1 and measured 1.5 cm. by 1.5 cm. and the resident had generalized reddened excoriated area on the R and L buttock that measured 11 cm. by 13 cm. A NN, dated 8/7/2015 for the 7-3 shift, included that the sacral wound was measured and treated. Further review of the NN from 8/8 through 8/17/2015 did not include any other reference to the sacral wound. The following NN revealed a reference to the LLE; A NN dated 8/7/2015 at 8 a.m. revealed .dressing intact and dry on lower extremities . There was no mention of the sacral dressing. A NN dated 8/10/2015 for the 3-11 shift included that the treatment to the BLLL was completed with no documentation about the sacral wound. A NN dated 8/11/2015 at 10 p.m. included; drg (dressing) CDI (clean, dry, intact) to lower extremities.A NN dated 8/12/2015 revealed; tx (treatment) done to B/LLE (bilateral lower extremity) and RUE (right upper extremity). There was no mention of any sacral dressing completed. A NN dated 8/14/2015 for the 7-3 shift included that the resident had a surgical debridement of the L ankle.A NN dated 8/16/2015 for the 3-11 shift included that wounds were dressed but it did not specify which wounds. From 8/7 through 8/16/2015, a total of 10 days, Resident #3 did not have a prescribed wound treatment completed. A total of 30 different shifts and 30 assigned CNAs during the 10 day period, from 8/8 through 8/17/2015 who did not report a sacral wound. In addition, for 10 consecutive days, licensed nursing personnel on the 11-7 shift, conducting 24 hour (hr.) chart checks, did not note the discrepancy between the POS and TAR related to the sacral wound treatment. During an interview with the surveyor on 8/17/2015 at 4:40 p.m. and on 8/19/2015 at 11:05 a.m., the DON stated that 24 hr. chart checks are completed daily by a nurse on the 11-7 shift and it included but was not limited to; comparing the POS with the TAR and checking for any transcription discrepancies. In addition, the surveyor asked what the facility protocol was for a resident admitted with a wound and the DON stated that POs are obtained and transcribed onto the TAR, a PU Flow Sheet and/or a Surgical Wound, Open [MEDICAL CONDITION]/Sore Flow Sheet were to be initiated and completed weekly by the wound nurse which would include but not limited to measurements and low air loss mattress is obtained. The facility was unable to provide any flow sheets to the surveyor for Resident #3. During an interview with the surveyor on 8/17/2015 at 4 p.m., the RN UM #1 stated that CPs are reviewed and updated at anytime including readmission. Additionally, the TAR confirmed the 8/7/2015 POS for a SA to be completed twice weekly and was initialed/signed as completed on 8/10/2015 by a 3-11 shift, RN #2, however, there was no code documented or any reference in the NN on 8/10/2015 to the results of the skin assessment. In a follow-up statement signed by RN #2, faxed to the NJ Department of Health (NJ DOH) on 8/24/ from the DON, RN #2 documented; Skin check done on 8/10/2015, however, sacral wound not observed. During a post survey telephone interview with the DON on 9/10/2015 at approximetely 4 p.m., the surveyor asked the DON if she investigated further if RN #2 had turned the resident over during the SA to view the skin and the DON stated that she was not sure the resident was turned over. A Summary of Investigation, faxed to the NJ DOH on 8/24/2015 from the DON included but not limited to the following; on 8/17/2015 Resident #3 was observed with sacral wound without treatment applied (and) .undated (dressing) treatment applied to the BLL (bilateral leg) wounds. Resident #3 admitted to the facility (on 7/20/2015) with a Stage II Sacral Wound and readmitted on [DATE] with a deteriorated PU with tunneling. Further clarification with the Admitting Nurse revealed the presence of slough in the wound bed. At treatment was applied at this time. The medication /treatment orders were endorsed to the 11-7 RN for transcription. During the transcription process, the treatment of [REDACTED]. It was not corrected on chart check as the orders were transcribed on the 11-7 shift .The sacral wound assessment on 8/17/2015 reflect no further deterioration. Per nursing statements, all leg wound treatments were administered . The Summary Conclusion revealed; The sacral wound has not demonstrated deterioration since re-admission on 8/7/2015 until assessment on 8/17/2015. Review of written statements, from the licensed nursing staff, faxed to the NJ DOH on 8/24/2015 from the DON included that treatments to the leg ulcers were completed on the 3-11 shift from 8/7 through 8/16/2015 but not documented on the TAR. Review of the Summary Investigations Findings included that the sacral treatment ordered 8/7/2015 was endorsed to the 11-7 shift RN for transcription, however, during the transcription process, the treatment was overlooked and it was not corrected on chart check as the orders were transcribed on the 11-7 shift. During an interview what the surveyor on 8/17/2015 at 10:15 a.m. and 8/19/2015 at 4:30 p.m., the DON stated there was no facility policy on how to complete a wound treatment but nurses follow standards of practice. The DON was not sure if the date needed to be documented on the dressing. During an interview with the surveyor on 8/19/2015 at 4 p.m. the RN UM #1 stated that facility protocol and nursing standard of practice when a wound treatment/dressing change is completed, the date it was done is written on the outer bandage. The immediate jeopardy which began on 8/7/2015 and was identified on 8/17/2015, was lifted on 8/17/2015 as evidenced by the implementation of an acceptable plan of correction as follows; 1. The physician and/or Nurse Practitioner was notified and the treatment order was transcribed to the TAR and completed, a low air loss mattress was placed on the bed on 8/17/2015. 2. All resident treatment orders will be audited weekly beginning 8/17/2015 to ensure all treatments are being administered per physician order. 3. The DON will review all new treatment orders and corresponding TARS weekly to ensure all orders are being properly transcribed and administered. Inservices began for licensed nursing staff related to proper transcription and implementation of physician orders [REDACTED]. Inservices began for CNAs related to reporting skin concerns to the nursing staff when treatments are not present. New and re-admission orders [REDACTED]. 4. Weekly random audits will be completed by the DON on wound treatments to ensure they are done per physician orders [REDACTED]. This deficient practice continues at a lower scope and severity of 309D as evidenced by the following; B. Based on observation, interviews and review of the MR and other facility documentation, it was determined that the facility failed to administer and/or document the refusal of, physician ordered wound treatments for 1 of 3 sampled residents (Resident #1). This deficient practice is evidenced by the following;1. According to the Nursing Admission Assessment, Resident #1 was admitted to the facility in 8/2015 with [DIAGNOSES REDACTED]. In addition, the Assessment indicated that Resident #1 had a Right (R) Forearm (FA) skin tear measuring 3.0 centimeters (cm.) by 2.5 cm.An admission Skilled Nurses Note (NN), dated 8/12/2015, indicated Resident #1 needed total assistance for all activities of daily living (ADLs) and was incontinent of bowel and bladder. Although, the 8/12/2015 NN described skin observations and included a R FA Scab measuring 1.5 cm by 0.5 cm. there was no indication in the NN of a skin tear with a dressing.Review of the Plan of Care and Accountability sheet, dated 8/12/2015, did not include any indication that Resident #1 had a wound.A Physician order [REDACTED]. Apply Triple Antibiotic Ointment (TAO), then cover with a clean dry dressing (CDD) once daily for 5 days then re-evaluate.Review of an 8/2015 Treatment Administration Record (TAR) confirmed the 8/12/2015 order for the skin tear treatment and noted that it was to be completed on the 3-11 shift. The TAR was not signed/initialed to indicate the treatment was done from 8/12 through 8/18/2015, for a total of seven of seven missed opportunities. Review of the back of the TAR and NN from 8/12 through 8/18/2015 did not indicate the treatment was done or any reason why the treatment was not completed as ordered.During a tour of the unit by the surveyor on 8/17/2015 at 9 a.m., the Director of Nursing (DON) stated that Resident # 3 did not have any wound. Resident #1 did not want to be disturbed at that time and the residents forearms were not observed by the surveyor at that time.During an interview with the surveyor on 8/19/2015 at 11:50 a.m., the RN UM #1 stated that she went in to look at Resident #1's dressing earlier in the morning on 8/19/2015, the second day of survey, after she realized there had been a treatment order for the R FA. The RN UM noted the date on the dressing she removed from the R FA was 8/4/2015; she then removed the dressing, discarded it and redressed it. The RN UM added that although she is the UM, she had been assigned to give medications lately so she was unable to follow up on her usually UM duties. Additionally, the wound care was being done by the 3-11 shift which had been recently changed from the 7-3 shift, within the last couple of months, so she did not realize Resident #1 had a wound.On 8/19/2015 at 11:50 a.m., the surveyor along with the RN UM observed a small scab on Resident #1's R FA where the 8/4/2015 dated dressing had been removed. Resident #1 stated she did not remember any staff member asking her about the R FA dressing prior to 8/19/2015. A Summary of Investigation, faxed to the NJ DOH on 8/24/2015 from the DON included that Resident #1 was admitted to the facility (on 8/12/2015) with a treatment (dressing) on the R FA which was dated 8/4/2015. The summary also noted that the R FA dressing was still intact on 8/19/2015. The DON included that RN #2, RN #4 and LPN #4 all confirmed that the resident was offered treatments several times on their shifts but the resident refused. The DON concluded that Resident #1 had a history of [REDACTED]. Review of the MR by the surveyor did not indicate that Resident #1 refused any treatment to the R FA or that a physician was notified that the resident was refusing. During an interview with the surveyor on 8/19/2015 at 12 p.m. and 1:10 p.m. the RN UM and DON confirmed that if a treatment, ordered by the physician is not done, it was be documented in the TAR and/or in the NN. In addition, the physician should be made aware that the treatment was not completed. Review of an undated facility policy titled; Wound Prevention and Wound Care Protocols included but was not limited to the following; Daily skin observations will be conducted by the CNA on each shift during the rendering of care and the CNA will report the findings to the nurse. The CNA will also notify the nurse of any changes in a resident's skin condition at the time that these changes are identified. The nurse will examine the area, document the findings in the residents medical record .revise the residents plan of care. Pressure Ulcer Staging Definitions: Stage II- Blister or other skin opening. Partial thickness skin loss involving the epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow. Stage III Skin breakdown exposing subcutaneous tissue. Full thickness skin loss involving damage to subcutaneous tissue that may extend down to but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Review of an undated facility policy titled; Pressure Ulcer Prevention/Management Program included but was not limited to the following; Skin observations will be conducted daily by care givers during the provision of providing care. Noted changes will be reported .Residents that are at high risk for skin impairment will have specific interventions on a care plan. The interventions will be communicated to the nursing assistant as a reminder to the nursing assistant to report any unusual skin conditions immediately to the nurse . If a resident scores 12 or less on the Braden Scale; has a pressure ulcer, or develops a pressure ulcer, the Wound Care Protocol will be implemented The Interdisciplinary Team will discuss the evaluation and a specific individualized plan of care will be developed to address the resident's needs and risk factors . A team that consists of the Nurse and /or Unit Manager and Wound Specialist Nurse Practitioner will conduct wound rounds weekly. Wounds will be monitored and descriptions will be recorded in the Wound Specialist Nurse practitioner's progress Notes, as well as on the PU monitoring form, to note the status of the wound, the degree of progress and response to treatment. During wound care treatments the nurse will observe the condition of the wound bed and surrounding area to assure the area is clean and appropriate treatment is being done . Review of an undated facility Staff Nurse (LPN) and (RN) Job Descriptions included but was not limited to the following; .administration of all medications and treatments as ordered and in accordance with accepted standards of clinical practice. NJAC: 8:39-27.1

Complaint #: NJ CROSS REFERENCE F 309 Based on observation, interviews and review of the Medical Record (MR) and other facility documentation, it was determined that the facility failed to consistently implement timely interventions, transcribe and follow physician orders [REDACTED].#3). Resident #3 was readmitted to the facility on [DATE] with a Sacral PU measuring 2 centimeters (cm) by 1.8 cm. with tunneling, however, there was no documented measurement of the depth of the tunneling. A sacral wound treatment, ordered by the physician at readmission, on 8/7/2015, was not completed for 10 days, from 8/7 through 8/16 because it had not been transcribed to the 8/2015 Treatment Administration (TAR) until 8/17/2015, the first day of survey. On 8/17/2015, Resident #3 was observed by the surveyor without a Sacral PU dressing; the facility staff then reviewed the MR and the treatment was initiated. On 8/17/2015, 10 days after the initial physician order, the Sacral PU increased in size from 2 cm. by 1.8 cm. with no depth of tunneling measured and was assessed by the facility Registered Nurse Unit Manager (RN UM #1) as a Stage III, measuring 3 cm. by 3 cm. with 2 cm. tunneling. Additionally, the RN UM #1 noted a new Right (R) Lateral Sacral Stage II PU measuring 1.5 by 1.5 cm., and R and left (L) buttock excoriation measuring 11 cm. by 13 cm. For a period of 10 days, from 8/7/2015 through 8/16/2015, facility licensed nursing staff, on the 11-7 shift, completed 24 hour chart checks on Resident #3's MR and did not note the discrepancy of the physician ordered Sacral PU treatment and/or the lack of the Sacral wound treatment documention on the TAR. For a period of 11 days, on 3 shifts, from 8/7/2015 through 8/17/2015, there was no documentation that any of Resident #3's care givers reported the Sacral PU to a supervisor. A skin assessment (SA) was signed/initialed as completed by a Registered Nurse (RN #3) on 8/10/2015, 3 days after admission, however, there was no documentation in the MR or on the SA regarding any of Resident #3's wounds including the Sacral PU. The facility's failure to implement timely interventions to promote wound healing including but not limited to; physician ordered wound treatments, consistently and accurately conduct skin assessments (SA), report any change in skin condition, implementation of pressure relieving devices, transcribing physician orders [REDACTED].#3. The facility Administrator and Director of Nursing (DON) were notified of the IJ on 8/17/2015 at 3:15 p.m., the first day of survey. The IJ which began on 8/7/2015, was lifted based on an acceptable plan of correction (POC) which was implemented on 8/17/2015 at 5 p.m. 1. See Example #1. The immediate jeopardy which began on 8/7/2015 and was identified on 8/17/2015, was lifted on 8/17/2015 as evidenced by the implementation of an acceptable plan of correction as follows; 1. The physician and/or Nurse Practitioner was notified and the treatment order was transcribed to the TAR and completed, a low air loss mattress was placed on the bed on 8/17/2015. 2. All resident treatment orders will be audited weekly beginning 8/17/2015 to ensure all treatments are being administered per physician order. Care Plans for those residents with treatment orders will be reviewed to ensure that the appropriate interventions are in place beginning 8/17/2015. 3. The DON will review all new treatment orders and corresponding TARS weekly to ensure all orders are being properly transcribed and administered. Inservices began for licensed nursing staff related to proper transcription and implementation of physician orders [REDACTED]. Inservices began for CNAs related to reporting skin concerns to the nursing staff when treatments are not present. New and re-admission orders [REDACTED]. 4. Weekly random audits will be completed by the DON on wound treatments to ensure they are done per physician orders [REDACTED]. NJAC 8:39-27.1 (e)

A. Based on observation, interviews and medical record review, it was determined that the facility failed to administer medications according to physician orders, facility policy, and acceptable nursing standards of practice for 1 of 4 nurses observed during the medication pass conducted on 10/22/14. At 8:05 a.m. on 10/22/2014, the Licensed Practical Nurse (LPN #1) did not check Resident # 9's arm (identification) band prior to administering medications. This resulted in Resident # 9 receiving and ingesting incorrect medications. The Immediate Jeopardy (IJ) was identified by the surveyor on 10/22/14 at 8:05 a.m. and the Director of Nursing (DON) was notified on 10/22/2014 at 8:15 a.m. The IJ was corrected on 10/22/14 at 2:55 p.m. based on an acceptable plan of correction which was implemented by the facility. This deficient practice was evidenced by the following: On 10/22/14 at 8:05 a.m., LPN # 1 administered [MEDICATION NAME]/Chon, Potassium and Requip to Resident # 9 who resided in room [ROOM NUMBER]. However, these medications were ordered for Resident #10, who resided in room [ROOM NUMBER]. The nurse failed to check Resident #9's arm (identification) band for the correct resident identification. Further review of Resident # 9's Medication Administration Record [REDACTED] On the same day at 8:25 a.m., the surveyor reviewed the MAR indicated [REDACTED]#10, who resided in room [ROOM NUMBER]. When interviewed at the time, LPN # 1 told the surveyor that he had given the incorrect medications to Resident # 9. LPN # 1 also stated that he did not check Resident # 9's arm (identification) band prior to administering the medications. LPN # 1 added that there was no photo of Resident # 9 on the MAR. LPN # 1 stated that he was not familiar with this resident and that this was the first time he had worked on the unit independently. Immediately after this interview, the surveyor ended the medication pass and reported this information to the Director of Nursing (DON), who was at the nurse's station. LPN #1 was immediately removed from medication pass duties by the DON. When interviewed by the surveyor on 10/22/14 at 11:25 a.m., the DON, in the presence of the Consulting Pharmacist, stated that nurses were to identify residents by name, then by their name (identification) band or by the resident's photo. When interviewed further, the DON stated that she confirmed that there was not a photo of Resident # 9 on the MAR. The Consulting Pharmacist stated that LPN #1 should have used the "five rights" of medication administration (Right Patient; Right Medication; Right Dose: Right Time; and Right Route) prior to administering the medications to Resident # 9. The Consulting Pharmacist stated that LPN # 1 should have checked Resident #9's arm (identification) band. When interviewed by the surveyor on 10/22/14 at 12 p.m., a second LPN stated that Resident # 9 had initially refused his/her prescribed medications but then agreed to take some of them later. The following Plan of Correction was initiated by the facility: 1. The nurse (LPN #1) was removed from the cart and another nurse took over for the conclusion of the medication pass. 2. Resident # 9 was informed he received the wrong medications. The physician was called and ordered the staff to take vital signs every shift. No changes in resident condition was noted and no change by physician in medications for Resident # 9. 3. Medication error forms were filled out and statements taken. The nurse who committed the errors (LPN # 1) was in-serviced by the consultant pharmacist on the 5 rights of medication pass and other medication pass administration information on 10/22/14. 4. All residents were reviewed to determine that they have name bands and pictures on the MAR for identification. 5. Pharmacist consultant will do in-services with facility staff on the medication pass including the 5 rights and proper medication administration on all three shifts on 10/22/14. 6. All nursing staff will be monitored by facility and/or Consulting Pharmacist over the next quarter to identify nurses who were inconsistent with med pass procedures. This consultant will train the DON and a designee on proper medication pass process for new hires. The facility will notify the Consulting Pharmacist of new hire and schedule them for a medication pass observation once orientation is completed. The Consulting Pharmacist will observe nursing staff monthly as part of Quality Improvement (QI) program. 7. The Consulting Pharmacist will, as part of QI, report on the findings of the medication pass observations performed monthly on the nursing staff as part of identifying issues and corrective actions needed. Any errors identified during these monthly medication pass observations will be addressed immediately. B. This deficiency continued at a scope and severity of a "D" level based on the evidence in Part B. Based on observation, interview and record review, it was determined that the facility failed to administer medication according to nursing standards of practice. This deficient practice was identified for 1 of 5 residents (Resident #16) reviewed during the medication pass and was evidenced by the following: During the medication pass that was conducted on 10/23/14 at 10:05 a.m., the survyeor observed LPN # 2 pour and administer [MEDICATION NAME], Aspirin, [MEDICATION NAME] and [MEDICATION NAME]. The nurse entered the resident's room with the medications, handed the medications to Resident # 16 who ingested them. After Resident # 16 took the medications, LPN # 2 performed a finger stick blood sugar (FSBS) test on Resident # 16. The result of the FSBS was a blood sugar level of 340 milligrams per deciliter (mg/dl). Based on the results of the FSBS, Resident # 16 had an order to receive 6 units of [MEDICATION NAME] Insulin. LPN # 2 returned to the medication cart and prepared the 6 units of [MEDICATION NAME] Insulin from a Flex-Pen. Once prepared, LPN # 2 entered the resident's room to administer the insulin medication to the Resident #16. At this time, the surveyor stopped medication pass and spoke with the Consulting Pharmacist who had been standing at the nurses' station. A review of the MAR indicated [REDACTED]. LPN # 2 stated that Resident # 16 had a routine order for 18 units of [MEDICATION NAME]as well as the (PRN) order for [MEDICATION NAME] insulin. The amount of insulin to be administered was based on the results of the FSBS results. The routine (18 units) [MEDICATION NAME]order was to be administered daily at 7:30 a.m. The FSBS was ordered to be obtained at 7:30 a.m. with the PRN [MEDICATION NAME]to be administered, if required, at 7:30 a.m. A review of the PRN order instructed the nurse to give 6 units of insulin with the 18 units to be given with breakfast. Further review of the MAR, in the presence of the Consulting Pharmacist and LPN # 2, revealed that the [MEDICATION NAME], Aspirin, [MEDICATION NAME] and the [MEDICATION NAME] medications were all plotted to be given at 8 a.m., over two hours prior to the time that LPN #2 administered them to Resident # 16. According to the facility's policy titled, "Medication Administration General Guidelines", medications were to be administered in accordance with written orders of the attending physician. The nurse would identify the patient with medication times and requirements for administrations then flag them to be administer AC (Before meals), PC (After meals), with meals or according to specific written direction or manufactures precautions. Medications were to be administered within 60 minutes of scheduled time, except before or after meal orders, which were to be administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medication were to be administered according to the established medication administration schedule for the facility. NJAC: 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to identify and administer medications to the correct resident. The Licensed Practical Nurse (LPN #1) administered incorrect medications to one resident, Resident #9. This resulted in an immediately jeopardy situation for Resident #9. The immediate jeopardy was identified on 10/22/14 at 8:05 a.m. and corrected on 10/22/14 at 2:55 p.m. based on an acceptable plan of correction implemented by the facility. The deficient practice continued at a lower scope and severity. A) During the initial tour conducted on 10/21/14, the nurse stated Resident #9 was alert, oriented and could make his/her needs known to staff. According to the medical record Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. On 10/22/14 at 8:05 a.m., the surveyor observed LPN #1 pour [MEDICATION NAME]/Chon, Potassium and Requip to administer to Resident #9. LPN #1 entered the resident's room with the medication, identified the resident by a first name and handed the medications to the resident. LPN #1 did not check the resident's arm (identification) band. Resident #9, who was alert, took the medications from LPN #1 and ingested them. Resident #9 then requested pain medication. LPN #1 exited the room to review the resident's Medication Administration Record [REDACTED]. Resident #9 refused the [MEDICATION NAME] and stated, "I want [MEDICATION NAME]." LPN #1 left the room with the [MEDICATION NAME] and reviewed the MAR indicated [REDACTED]. Resident #9 told LPN #1 that the LPN "might be looking at the wrong patient." At 8:25 a.m., the surveyor reviewed the MAR indicated [REDACTED]. When interviewed at this time, LPN #1 told the surveyor that he had given the incorrect medications to Resident #9. LPN #1 also stated that he did not check Resident #9's arm (identification) band prior to administering the medications. LPN #1 added that there was no photo of Resident #9 on the MAR. LPN #1 stated that he was not familiar with this resident and that this was the first time he had worked on the unit independently. Immediately after this interview, the surveyor ended the medication pass and reported this information to the Director of Nursing (DON) who was at the nurses' station. LPN #1 was immediately removed from medication pass duties by the DON. As a result, Resident #9, who resided in room [ROOM NUMBER], erroneously received and ingested six medications, and was offered a seventh medication and refused, that were prescribed for Resident #10, who resided in room [ROOM NUMBER]. When interviewed by the surveyor on 10/22/14 at 11:25 a.m., the DON, in the presence of the Consulting Pharmacist, stated that nurses were to identify residents by using their name, then by their name (identification) band or by the resident's photo. When interviewed further, the DON stated that she confirmed that there was not a photo of Resident #9 on the MAR. The Consulting Pharmacist stated that LPN#1 should have used the "five rights of medication administration" (Right Patient; Right Medication; Right Dose: Right Time; and Right Route) prior to administering the medications to Resident #9. The Consulting Pharmacist stated that LPN #1 should have checked Resident #9's arm (identification) band. The surveyor reviewed the facility's policy titled, "Medication Administration General Guidelines" that stated medications were to be administered in accordance with written orders of the attending physician. Residents were to be identified before medication was administered. Methods of identification included: checking identification band; checking photograph attached to medical record; calling resident by name; and if necessary, verifying resident identification with other facility personnel. The facility instituted the following Plan of Correction: 1. The nurse was removed from the cart and another nurse took over for the conclusion of the medication pass. 2. Resident #9 was informed he received the wrong medications. The physician was called and ordered the staff to take vital signs every shift. No changes in resident condition was noted and no change by physician in medications for Resident #9 was noted. 3. Medication error forms were filled out and statements taken. The nurse who committed the errors was in-serviced by the consultant pharmacist on the 5 rights of medication pass and other medication pass administration information on 10/22/14. 4. All residents were reviewed to determine that they have name bands and pictures on the MAR for identification. 5. Pharmacist consultant will do in-services with facility staff on the medication pass including the 5 rights and proper medication administration on all three shifts on 10/22/14. 6. All nursing staff will be monitored by facility and/or consultant pharmacist over the next quarter to identify nurses inconsistent with med pass procedures. The consultant will train the DON and a designee on proper medication pass process for new hires. Facility will notify the consultant pharmacist of new hires and schedule them for observation once orientation will be completed. The consultant pharmacist will observe nursing staff monthly as part of Quality Improvement (QI) program. 7. The consulting pharmacist would, as part of QI, report on the findings of medication pass observations performed monthly on the nursing staff as part of identifying issues and corrective actions needed. Errors identified during these monthly med pass observations will be addressed immediately. B) The deficient practice continued at a lower scope and severity at an "E" level. During the medication pass observation conducted on 10/22/14 and 10/23/14, one nurse made 7 errors. As 22 opportunities for error were observed, this calculated to a 31% error rate. This was identified for 1 of 4 nurses observed and for 1 of 5 residents observed. LPN#2 administered medications more than 2 hours late to Resident #16 on 10/23/14. The deficient practice was evidenced by the following: The surveyor reviewed the physician's orders [REDACTED].#16 who was to receive [MEDICATION NAME] 12.5 milligrams (mg) by mouth (PO) daily, Aspirin 325 mg PO once daily, and [MEDICATION NAME] 75 mg PO once daily at 8 a.m. The resident also was to receive [MEDICATION NAME] 20 mg PO twice daily (BID) and Neuron 400 mg PO every 8 hours. Both of these medication were scheduled for 8 a.m. Additionally Resident #16 had an order to receive [MEDICATION NAME] 20 units (an insulin) by injection twice daily (BID) and [MEDICATION NAME] 18 units daily with the breakfast meal. These medications were also ordered to be administered at 8 a.m. All of the medications were administered at 10:05 a.m., over 2 hours late. At 10:05 a.m., the surveyor observed LPN # 2 pour and administer [MEDICATION NAME], Aspirin, [MEDICATION NAME] and [MEDICATION NAME] to Resident #16. After Resident # 16 took the medications, LPN # 2 performed a finger stick blood sugar (FSBS) test on Resident #16. The result of the FSBS was a blood sugar level of 340 milligrams per deciliter (mg/dl). Based on the results of the FSBS, Resident #16 was to receive 6 units of [MEDICATION NAME] Insulin. LPN #2 returned to the medication cart and prepared the 6 units of [MEDICATION NAME] Insulin from a Flex-Pen. Once prepared, LPN #2 entered the resident's room to administer the insulin medication to the Resident #16. At this time, the surveyor stopped medication pass and spoke with the Consulting Pharmacist who had been standing at the nurses' station. In the presence of the Consulting Pharmacist and LPN # 2, the surveyor reviewed the MAR indicated [REDACTED]# 16. In addition, Resident #16 had an as needed (PRN) order for [MEDICATION NAME] insulin. The amount of insulin to be administered was based on the results of the FSBS results. The FSBS was ordered to be obtained at 7:30 a.m. with the PRN [MEDICATION NAME]to be administered, if required, at 7:30 a.m. The surveyor reviewed the facility's policy titled, "Medication Administration General Guidelines" that stated medications were to be administered in accordance with written orders of the attending physician. The nurse would identify the patient with medication times and requirements for administrations then flag them to be administered AC (Before meals), PC (After meals), with meals, or according to specific written direction or manufacturer's precautions. Medications are to be administered within 60 minutes of scheduled time, except before or after meal orders, which were to be administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications were to be administered according to the established medication administration schedule for the facility. NJAC 8:39 - 29.3 (d) 8:39 -11.2(b)