Every finding on record at Fallsview Nursing and Rehabilitation Center

Complaint: 423561Repeat DeficiencyBased on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently provided for 5 of 6 residents (Resident #47, #68, #75, #78, and #106) reviewed for dietary preferences during meal observations. This deficient practice was evidenced as follows:1. On 3/15/26 at 9:20 AM, the surveyor observed Resident #47 in their room, sitting in a wheelchair (WC) eating breakfast. Resident #47 stated they were missing items from their tray. Surveyor observed Resident #47's breakfast tray ticket and tray. Resident #47 was missing a biscuit, one packet (pkt) of pepper and one pkt of ketchup. On 3/16/26 at 1:05 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #47.The admission Record (AR) (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to protein calorie malnutrition(a severe form of malnutrition characterized by a deficiency of both protein and calories), type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and high blood sugar levels,)and hypertension(high blood pressure).A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/5/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #68 scored 15 out of 15, which indicated the resident had normal cognitive function.A review of the Physician Order Summary Report (OSR) included a Physician Order (PO) dated 5/5/25 for, No added salt (NAS), Consistent Carbohydrate (CCD) diet, Regular texture, thin liquids consistency.A review of Resident #47 care plan (CP) revealed a nutrition CP with a focus, resident is at risk for malnutrition and other nutritional problems and interventions that included, provide and serve diet as ordered.2. On 3/15/26 at 9:22 AM, the surveyor observed Resident #68 in their room, sitting bed eating breakfast. Resident #68 stated they were missing items as well as had incorrect items from their tray. Surveyor observed Resident #68's breakfast tray ticket and tray. Resident #68 was missing a 4-ounce (oz) fruit cup, 4oz cranberry juice, a biscuit, 1pkt salt, 1 pkt of pepper and 1 pkt of ketchup. Resident #68 received a 4oz applesauce and a 4oz apple juice both items were not listed on the tray tickets, furthermore the resident's tray ticket indicated No apple products. On 3/15/26 at 9:40 AM, during the kitchen inspection, the surveyor interviewed the cook who stated he did not make enough biscuits for today's breakfast but could not state why the condiments were missing from the resident trays. On 3/16/26 at 8:54 AM, the surveyor observed Resident #68 breakfast tray being delivered. Resident #68's tray ticket had listed 1 pkt salt, 1 pkt pepper and 4oz cranberry juice, all three items were missing. Resident #68's tray contained a 4oz apple juice.On 3/16/26 at 9:15 AM, the surveyor reviewed the EMR of Resident #68.The AR documented the resident had diagnoses that included but were not limited to, multiple sclerosis (an autoimmune disease that affects the central nervous system), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and tinea unguium (a fungal infection).A review of the quarterly MDS, dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #68 scored 15 out of 15, which indicated the resident had normal cognitive function. The MDS further indicated that Resident #68 wears hearing aids and is dependent on staff for oral hygiene.A review of the OSR included a PO dated 6/17/24, Regular diet, Regular texture, thin liquids consistency, Dietary. No apple. Allergy to peach skin.A review of Resident #68's CP revealed a nutrition CP with the focus, Resident is a risk for malnutrition/dehydration and interventions that included, provide me with my food/beverages preferences.3. On 3/16/26 at 12:15 PM, the surveyor observed Resident #75 eating lunch in their room. Resident #75 stated they were missing a can of diet ginger ale. Diet ginger ale was listed on Resident #75's lunch ticket but not provided.On 3/16/26 at 1:10 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #75.The AR documented the resident had diagnoses that included but were not limited to retention of urine (a condition characterized by the inability to empty the bladder completely or at all), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood effectively) and protein-calorie malnutrition.A review of the quarterly MDS, dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #75 scored 13 out of 15, which indicated the resident had normal cognitive function.A review of the OSR included a PO dated 5/21/25, Regular diet, Regular texture, thin liquids consistency.A review of Resident #75's CP revealed a nutrition CP with the focus, Resident is a risk for malnutrition related to advance age and an intervention that included, honor food preferences.4. On 3/16/2026 12:20 PM, the surveyor observed Resident #106 in their room eating lunch. Resident #106 stated they were given the incorrect vegetables. The surveyor observed chopped carrots on the resident's plate. A review of Resident #106's tray ticket revealed the resident was supposed to receive chopped oriental vegetables.On 3/16/26 at 1:15 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #106.The AR documented that the resident had diagnoses that included but were not limited to muscle weakness (a decrease in strength or power of muscle contractions), chronic obstructive pulmonary disease (a progressive lung disease), muscle wasting and atrophy (a loss or thinning of muscle tissue, leading to decreased muscle mass and strength).A review of the admission MDS, dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #106 scored 15 out of 15, which indicated the resident had normal cognitive function.A review of the OSR included a PO dated 3/10/26, Regular diet, chopped consistency, thin liquids consistency.A review of Resident #106's CP revealed a nutrition CP with the focus, Resident is a risk for malnutrition related to advance age and interventions that included, provide and serve diet as ordered and honor food preferences. 5. On 3/16/26 at 12:22 PM, the surveyor observed Resident #78 in their room eating lunch. The resident stated they received gravy on both the roast pork and mashed potatoes, when the tray ticket stated as a food preference, No gravy. Surveyor observed Resident #78's lunch tray with gravy on both the roast pork and mashed potatoes.On 3/16/26 at 1:20 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #78.The AR documented the resident had diagnoses that included but were not limited to cerebral palsy (is a non-progressive neurological disorder caused by abnormal brain development or brain injury that affects movement, muscle tone, and coordination), hyperlipidemia (high cholesterol) and irritable bowel syndrome (a common gastrointestinal disorder).A review of the quarterly MDS, dated [DATE], indicated the facility assessed the residents' cognition using a BIMS test. Resident #78 scored 13 out of 15, which indicated the resident had normal cognitive function. The MDS further indicated that Resident #68 wears hearing aids and is dependent on staff for oral hygiene.A review of the OSR included a PO dated 3/11/26, NAS (No added salt) diet, Regular texture, thin liquids consistency.A review of Resident #78's CP revealed a nutrition CP with the focus, Resident is a risk for malnutrition related to advance age and interventions that included, honor food preferences.On 3/17/26 at 9:45 AM, the surveyor interviewed the Food Service Director (FSD), who stated the resident's tray ticket and meal trays should match, and if the dietary department was to run out of a food item, we should speak to the resident to ask what alternative food item they would like. FSD was unable to state why any meal tray would have had missing condiments.On 3/17/26 at 10:00 AM the FSD provided the surveyor with a facility policy, Food Preferences with a revised date 5/2025. The policy explanation and guidelines revealed, 4. The dietary department will provided residents with meals consistent with their preferences as indicated on the tray card.On 3/19/26 at 2:30 PM, the surveyor met with the Director of Nursing (DON) and Licensed Nursing Home administrator (LNHA) to review concerns found during the survey. The DON stated all residents tray tickets should match their meal trays.On 3/20/26 at 11:30 AM, the surveyor met with the DON, LNHA and Regional Registered Nurse (RRN) for exit conference. No further pertinent information was provided.NJAC - 17.4(a)1, (e)

Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 4 of 24 residents (Resident #13, #14, #49, and #54) during the review of resident assessment. This deficient practice was evidenced by the following: The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 3/17/26 at 10:52AM, the surveyor interviewed MDS Coordinator (MDSC), who stated that she follows the Resident Assessment User's Manual (RAI Manual) guide on how to conduct a resident assessment for MDS. The MDSC further stated that every morning she would update and ensure that the sections in the MDS were completed timely and properly. The MDS must be submitted within two weeks of the Assessment Reference Date (ADR) look back period. At that time, the surveyor provided the MDS Coordinator (MDSC) with the list of 24 residents who had not completed an MDS in over 14 days. The surveyor also requested a copy of the resident's final validation report (generated after every MDS transmission) from the Centers for Medicare and Medicaid Services (CMS). The surveyor reviewed the final validation report from CMS with the MDSC, the 4 residents' MDS assessments that were not submitted within fourteen days of completion, as follows: 1. Resident #13 had an admission MDS assessment with an assessment reference date (ARD, the last day of the observation period) of 6/7/25 but was not transmitted until 6/23/25. (Submission was 17 days late). 2. Resident #14 had an admission MDS assessment with an ARD of 11/21/24 but was not transmitted until 12/10/24. (Submission was 18 days late). Resident #14 also had a Quarterly MDS with an ARD of 8/5/25 but was not transmitted until 9/2/25. (Submission was 28 days late). 3. Resident #49 had an admission MDS assessment with an ARD of 6/24/25 but was not transmitted until 7/11/25. (Submission was 17 days late). Resident #49 also had a Quarterly MDS assessment with an ARD of 8/5/25 but was not transmitted until 9/2/25. (Submission was 28 days late.) 4. Resident #54 had a Quarterly MDS assessment with an ARD of 8/8/25 but was not transmitted until 9/2/25. (Submission was 25 days late.) On 3/18/26 at 2:47 PM the surveyor informed the LNHA and DON of the late transmittal of the MDS.On 3/19/26 at 10:10 AM the survey team met with the LNHA and DON and no further information was provided. NJAC 8:39-11.1

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a.) a Resident with a newly identified pressure ulcer (PU) received care consistent with professional standards of practice for 1 of 3 residents reviewed for PU (Resident #42) and b.) pressure reducing low air loss mattresses were set according to residents body weight for 2 of 3 residents reviewed (Resident #7 and #42.)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 case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. A. On 3/16/26 at 9:30 AM, the surveyor observed Resident #42, who was sleeping, an air mattress was present, the air mattress was set at 280 pounds (lbs). On 3/17/26 at 10:15 AM, the surveyor observed Resident #42, had an air mattress on the bed, the setting was set at 280 lbs. On 3/17/26 at 11:30 AM the surveyor reviewed the electronic medical record (eMR) for Resident #42. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but was not limited to; dislocation of internal right hip prosthesis, difficulty in walking, muscle wasting (weakening, shrinking and loss of muscle). A review of the Quarterly Minimum Data Set (qMDS), an assessment tool dated 2/6/26, reflected a brief interview for mental status (BIMS) score of 15 out of 15, which demonstrated the resident was cognitively intact. A review of the individualized comprehensive care plan (ICCP) for Resident #42, identified a focus area for potential skin impairment dated 1/5/24 with a most recent revision date of 2/25/26, with intervention that included but were not limited to, wound consult, nutrition consult, treatment order, and a low air loss mattress. Further review of the ICCP revealed no new focus area for an actual skin breakdown. A review of the eMR revealed that the readmission assessment for 1/30/26 was not completed. A review of the eMR skin alteration risk assessment, dated 2/11/26 at 1:13 PM, revealed that the resident had a closed a blister area on the sacrum, with no further comprehensive skin assessment for a new skin alteration which would include the size and description of the wound area. A review of the eMR facility document in evaluation, titled, JLMC Skin Observation, dated 2/11/26 at 3:15 PM, signed by the Director of Nursing (DON), revealed a sacral wound with a description of a blister and small scabs with no further description of the wound. A review of a contractor visit report for wound care, dated 2/17/26, revealed a wound assessment for a stage III sacral pressure ulcer that was acquired on 2/11/26 that measured 12 cm x 8 cm x0.2 cm. Further review revealed that there was a moderate amount of serosanguineous (pink to light red thin fluid) drainage with eschar (thick dry black layer of dead tissue that covered 76% -100% of the wound bed. Further review revealed a wound treatment that included to cleanse area with normal saline (NS) and then apply medical honey to sacral wound and cover with a boarded gauze dressing daily and as needed; provide pressure relief and offloading for the wound and to use a low air loss mattress with inflation and setting verified and that the residents weight was 183.19 pounds (lbs.). Further review of the eMR revealed that there were no further weekly wound assessments from the wound consultants with the assessment for the sacral wound for each week from 2/24/26-3/19/26. A review of the eMR facility document in evaluations, titled, JLMC Skin Observation, dated 2/18/26 at 12:22 PM, revealed that a treatment was in progress to the sacrum and there were no further wound assessment documentation with the wound description to indicate the progression of the wound. A review of the eMR facility document in evaluations, titled, JLMC Skin Observation, dated 3/4/26 at 1:06 PM, revealed that a treatment was in progress to the sacrum and that there were no further wound assessment documentation with the wound description that would include the size and description of the wound. A review of the eMR facility document in evaluations, titled, JLMC Skin Observation, dated 3/11/26 at 3:24 PM, revealed that a treatment was in progress to the sacrum and that there were no further wound assessment documentation with the wound description that would include the size and description of the wound. A review of the eMR revealed the facility failed to do a Braden scale (The Braden Scale assesses pressure injury risk through six subscales (Sensory Perception, Moisture, Activity, Mobility, and Nutrition, Friction/Shear) rated 1-23) upon readmission to the facility from acute care on 1/30/26. A review of February 2026 Treatment Administration Record (TAR) revealed an order to conduct a full body assessment weekly on Wednesday 7a-7p shift. Complete observations form in evaluations every day shift every Wednesday for skin check start date 2/4/26. A further review of the TAR further revealed signatures of completion on 2/4/26, 2/11/26, 2/18,26 and 2/25/26. On 3/18/26 at 10:48 AM, the surveyor interviewed registered nurse (RN #3) who stated, when a resident is admitted to the facility or is a re-admission the nurse is supposed to do an admission assessment which includes a skin assessment. There is an area to write a description of the area in question, and it has a measurement section. On 3/18/26 at 11:10 AM, the surveyor interviewed RN #4 who stated, If a resident would present a new skin issue, the nurse would need to contact the doctor and obtain orders for the resident. The orders would include wound care consult, turning the residents every 2 hours, and a low-air-loss mattress. The nurse would document in the 24-hour nursing round report and would notify upper management. The nurse is responsible to do a Risk Assessment in the eMR. The Risk Assessment should contain a description of the altered skin integrity, including staging and size. RN#4 further stated that the facility used a wound contractor and that the nursing staff would write in a logbook, and the contractor would check the logbook weekly. On 3/18/26 at 10:58 AM, the surveyor interviewed the DON who stated, if a new skin alteration is found the nurse would be required to do a risk assessment and notify upper management. During morning meeting of the upper management, the department heads and the nursing staff would talk about skin integrity issues. The DON further stated that the facility does not complete an investigation for the development of wounds or skin integrity issues. On 3/18/26 at 12:15 PM, the survey team met with the licensed nursing home administrator LNHA, the DON and the regional Director of Nursing (RDON), who stated that an investigation report could not be provided for the 2/11/26 skin alteration that the resident had developed. A review of the facility's admission Process policy, with an effective reviewed and revised date of 8/2025, included but was not limited to.policy of this facility to follow a consistent and complete process for admission of the resident into the facility.the process of admission is an interdisciplinary process consisting of a clinical nursing admission process.each disciplines process is unique in content and timeline completion and individualized to that resident.The admitting nurse will complete all the required assessments.Interim Plan of Care/ baseline care plan with 48- hours of resident readmission.skin assessment will be completed within the first 8 hours of an admission including the Braden Scale and /or [NAME]. A review of the facility's readmission policy, with an effective reviewed and revised date of 12/2025, included but was not limited to. to ensure the establishment of proper medical records subject to the length of discharge for readmitted residents.When a resident is out of the facility but returns within 7 days, nursing staff will continue to use the previous record.Return within 7 days.If the resident returns within 7 days, the resident will be logged into the admission log as a readmit to allow continuation of the same record.complete a NEW comprehensive admission assessment.complete a readmission note including time of readmission, condition of readmission. A review of the facility's Wound Care policy, with an effective reviewed and revised date of 1/2024, included but was not limited to.the purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Stage 1; 8) measure and document area.Stage 2; 9) measure and document area adjust care plan.Stage 3; 9) measure wound.Stage 4; measure wound and document appearance.Suspected Deep Tissue Injury; 2)measure wound and document appearance.Skin tears: 7)measure wound and document appearance, each skin tear is to have its own separate documentation sheet. A review of the facility's Charting and Documentation policy, with an effective reviewed and revised date of 4/2025, included but was not limited to. any changes in the resident's medical, physical.shall be documented in the medical record.documentation in the medical record will be.complete and accurate.the assessment data and/or any unusual findings obtained during an procedure or treatment.the signature and title of the individual documenting. A review of the facility's Care Plans, Comprehensive, Person Centered policy, with an effective reviewed and revised date of 4/2025, included but was not limited to.a comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.8) the comprehensive, person centered care plan will.g)incorporate identified problem areas; h)incorporate risk factors associated with problems; k)reflect treatment goals, timetables and objectives in measurable outcomes; i)identify professional services that are responsible for each element of care; m)aid in preventing or reducing decline in the residents functional status and/or functional levels; o) reflect currently recognized standards of practice for problem areas and conditions. B. 1.On 3/16/26 at 9:30 AM, the surveyor observed Resident #42, who was sleeping, an air mattress was present, the air mattress was set at 280 pounds (lbs). On 3/17/26 at 10:15 AM, the surveyor observed Resident #42, had an air mattress on the bed, the setting was set at 280 lbs. On 3/17/26 at 11:30 AM, the surveyor reviewed the electronic medical record (eMR) for Resident #42. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but was not limited to; dislocation of internal right hip prosthesis, difficulty in walking, muscle wasting (weakening, shrinking and loss of muscle). A review of the Quarterly Minimum Data Set (qMDS), an assessment tool dated 2/6/26, reflected a brief interview for mental status (BIMS) score of 15 out of 15, which demonstrated the resident was cognitively intact. A review of a contractor visit report for wound care, dated 2/17/26, revealed a wound assessment for a stage III sacral pressure ulcer that was acquired on 2/11/26. Further review revealed to provide pressure relief and offloading for the wound and to use a low air loss mattress with inflation and setting verified. A review of Resident #42 weights in the eMR revealed that on 2/4/26 the resident's weight was 183.0 lbs. and on 3/4/26 the resident's weight was 182.8 lbs. A review of the Order Summary Report revealed an order dated 1/30/26 for an air mattress and to check for placement, function and setting every shift. A review of March 2026 Treatment Administration Record (TAR) revealed the following order dated 1/31/26 for an air mattress and to check for placement, function and setting every shift. Further review of the TAR revealed signatures of completion on 3/15/26, that ensured the mattress was in operating order. On 3/15/26 and 3/16/26 during surveyor observation, the air mattress settings were set for 280lbs. A review of the residents' weights indicated the weight was 182.8 lbs. on 3/4/26, which would indicate a 97.2 lb. difference from the setting on the air mattress. On 3/18/26 at 10:48 AM, the surveyor interviewed the registered nurse (RN #3) who stated the facility policy and expectation for the staff for a resident who required an air mattress would be that the nurse would sign the TAR for the mattress. When a nurse signs the TAR, that would ensure that the mattress is functioning properly, in working order, and set to the correct weight. She further stated that if the weight setting was not correct the mattress could be too hard or too soft for the residents and that could cause pressure ulcers. She further stated that low air loss mattresses are used to reduce and prevent pressure ulcers, the nurse signs the TAR for the mattress. That signature is a statement that the nurse checks that it was in working order and set to the correct weight setting. If the weight setting is not set correctly the mattress could be too hard or too soft for the residents and that could cause pressure ulcers. If the certified nursing assistant finds an issuer with the mattress, they are to report it immediately. On 3/18/26 at 11:10 AM, the surveyor interviewed RN #4 who stated, air mattress setting needs to be correct on the unit. The nurse knows the resident's weight because it is in the vital signs as well as in the top right corner of the medication assessment record. When a nurse signs the order off in the MAR or TAR you can flip through the screens to ensure the unit settings are correct. On 3/18/26 at 10:58 AM, the surveyor interviewed the DON who stated that her expectation of staff according to the facility policy for residents who use air mattresses is that if a nurse would sign the MAR or TAR for the low air loss mattress, the signature would indicate that the unit was checked and the settings were correct. The DON further stated that air mattresses are used as a preventative to relieve pressure from bony areas of a resident. On 3/18/26 at 12:15 PM, the survey team met with the LNHA, the DON and the RDON, and an investigation report could not be provided to the team for the skin alteration risk assessment, dated 2/11/26. A review of the facility's Use of Support Surfaces policy, with an effective reviewed and revised date of 8/2025, included but was not limited to.Support surfaces will be used in accordance with evidence based practice for residents with or at risk for pressure injuries.Pressure redistribution is the ability of a support surface to distribute load over the contact areas of the body to reduce the overall pressure and avoid areas of focal pressure.support surfaces will be utilized in accordance with the manufacturer's recommendations (including considerations and accommodations).the DON will maintain a list of support surfaces used in the facility, including product specifications. in the facility, including product specifications.for powered devices, or those requiring air, the licensed nurse will check each shift and as needed (PRN) for proper functioning and /or inflation.effectiveness of support surfaces will be monitored through ongoing assessment of the resident and /or wound. Considerations for alternative surfaces include b) development of new pressure injury, c) lack of progression towards healing or changes in wound characteristics. 2.On 3/15/26 at 11:25 AM, the surveyor observed Resident #7 in bed with his/her eyes closed with a specialty mattress in place. The resident's air mattress pump was set to a weight of 150 pounds (lbs.). The surveyor reviewed the electronic medical record (E-mar) for Resident #7. A review of the admission Record reflected that Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to; dementia and peripheral vascular disease (narrow or blocked blood vessels that reduce blood flow to the limbs and organs). A review of the annual Minimum Data Set (MDS), an assessment tool dated 2/26/26, reflected that Resident #7's cognitive skills for daily decision-making were severely impaired. The MDS further indicated that the resident's weight was 91 lbs., that they were at risk of developing a pressure ulcer, and that they had a pressure-reducing device for their bed. A review of the current Physician Order Summary Report (OSR) showed a Physician's Order (PO) for a low-air-loss mattress, with the function and settings to be checked every shift. A review of the current Treatment Administration Record (TAR) included documentation that indicated the specialty mattress was monitored for function and proper placement by the nurses every shift. A review of the resident's Care Plan indicated the resident is at risk for alteration in skin integrity with interventions that included but were not limited to; Low air loss mattress. On 3/17/26 at 10:15 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated that she was unsure what the air mattress setting for Resident #7 should be. She stated that she did not know what the numbers on the gauge indicated. The surveyor asked the LPN if it should be set to the resident's weight. The LPN replied that she wasn't sure. At 10:30 AM, the LPN told the surveyor that the unit manager informed her that the specialty mattress should be set to the resident's weight. The LPN confirmed that she had signed the TAR, which indicated she had checked the mattress for function and proper placement, even though she had not. On 3/18/26 at 2:50 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. A review of the facility's Use of Support Surfaces policy dated as revised 8/2025 reflected .Support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries .Support surfaces will be chosen by matching the potential therapeutic benefit with the resident's specific situation .Resident's size and weight .Support surfaces will be utilized in accordance with physician orders .For powered devices or those requiring air, the licensed nurse will check each shift and when needed for proper functioning and/or inflation. On 3/19/26 at 11:41 AM, no further information was provided. NJAC 8:39-27.1 (a)

Based on observation, interview, and a review of facility records, it was determined that the facility failed to ensure an accurate inventory of controlled medications (narcotic medications) dispensed from the facility's automated medication dispensing system (AMDS). The deficient practice was observed for 1 of 1 on the automatic medication dispensing system located in the facility's 1st floor medication room and was evidenced by the following: Repeat DeficiencyReference: 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 case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/17/26 at 11:30 AM, the surveyor requested the controlled substances count sheet (CSC) for the facility AMDS for the month of February and March 2026 from the Director of Nursing (DON).On 3/18/26 at 11:00AM, the surveyor asked the DON if she was able to locate the CSC sheets from February and March2026. She was unable to provide the surveyor with any CSC sheets for February and March of 2026 and acknowledge that the narcotic counts for the facility's AMDS are not being done daily. At that time, the surveyor requested that he be provided with the Inventory Count for Scheduled 2-5 medications in the facility's AMDS and a 14-day Transaction report for the AMDS.On 03/19/26 at 9:00 AM, the DON provided the surveyor with both the Inventory Count, Schedule 2-5 and the 14-day Transaction Report. A review of the Inventory count revealed that the facility had 6 control/narcotic medications available in the facility AMDS which included tablets of Ativan 0.5 mg (1/2 tablets), 20 tablets of Clonazepam 0.5 mg (1/2 tablets), 25 tablets of Lyrica 50 mg capsules, 10 tablets of Percocet 5/325 mg tablets, 20 tablets of Ultram 50 mg (1/2 tablets), and 19 tablets of Xanax 0.25 mg tablets.On 3/19/26 at 9:30 AM, the surveyor in the presence of Registered Nurse/Unit manager (RN#1/UM) and RN #2 observed the narcotic count of the AMDS machine. The surveyor observed that all count numbers matched the numbers that were on the Inventory Count, Schedule 2-5 sheet that was provided by the DON.On 3/19/26 at 10:00 AM, the surveyor interviewed the DON who acknowledged that the AMDS controlled substances count should be done daily and that a record of these counts should be accessible.On 3/19/26 at 11:00 AM, the surveyor presented the above concerns to the facility administrative team which included the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA), and the Regional Clinical Nurse.There was no additional information provided.A review of the facility's policy for Controlled Substances that was dated 09/30/25 and was provided by the DON which revealed the following: 6. The Charge Nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers. The Charge Nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify:Controlled substances that are destroyed are appropriately documented ; andMedications removed from either the automated dispensing system or medication cart/cabinet have a documented physician's order. 8. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and nurse going off duty must make the count together. They must document and report discrepancies to the Director of Nursing Services.NJAC 8:39-29.4(n)

Based on facility staff interviews and review of pertinent facility documentation, it was determined that the facility failed to provide a designated qualified Part-Time or Full-Time Infection Prevention and Control Nurse effective a.) 7/18/2025-8/25/2025 (38 days) and b.)10/14/2025-10/27/2025 (13 days). This deficient practice was evidenced by the following: Reference: (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) S483.80(b) Infection preventionist the facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must: S483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; S483.80(b)(2) Be qualified by education, training, experience or certification; S483.80(b)(3) Work at least part-time at the facility; and S483.80(b)(4) Have completed specialized training in infection prevention and control. On 3/17/26 at 10:22 AM, the Licensed Nursing Home Administrator (LNHA) stated the facility did not have a designated Infection Preventionist (IP) for the dates of a.) 7/18/2025-8/25/2025, b.)10/14/2025-10/27/2025. He further stated that the facility was trying to hire a permanent IP, and regional personnel were intermittently helping the facility through remote and phone access. On 3/19/36 at 11:48 AM, in the presence of the survey team, the LNHA, Director of Nursing (DON), and the Regional DON, acknowledged that the IP should be a designated part-time (pt) or full-time (ft) position within the facility as per federal regulations and guidelines. A review of the facility's policy, Infection Control Guidelines for all Nursing Procedures revised on 6/2025, subsection outbreak Plan updated 1/2026 revealed: required education. the IP will work in conjunction with the medical director to identify employee education required based on local, state, and federal guidance. the IP will coordinate the identification and provision of education with the staff educator, DON, Medical Director and Administrator.The IP will serve as the point of contact for the local, state, and federal agencies and keep up with changing guidance.The IP will be responsible to re-educate or coordinate re-education of staff based on changing guidance of health agencies. A review of the facility's policy, Coronavirus (Covid 19, Prevention and Control (New Jersey region), revised on 10/2/2025, revealed.General Guidelines; surveillance, vaccination, testing, infection control, antiviral treatment and antiviral chemoprophylaxis.Surveillance 1)The IP is responsible for monitoring public health advisories for the presence of Covid 19 in the geographical location of the facility.The IP and DON will train and educate staff on the prevention transmission of infectious agents.associated with healthcare.outbreak.The IP will initiate contact tracing.will conduct active surveillance of residents, staff and visitors.will maintain a line list to track all cases associated with the outbreak. A review of the facilities policy, Influenza Vaccine, revised 1/2026, revealed.The IP will maintain surveillance data on influenza vaccine and reported rates of influenza among residents and staff. NJAC 8:39-19.1 (b), 19.4(d) (e)

Based on interview and document review, it was determined that the facility failed to consistently complete; a.) pre-screening (criminal background check) for all employees, prior to hire, to ensure they had not been found guilty in a court of law of abuse, neglect, or misappropriation. This deficient practice was identified for; 7 of 185 and b.) conduct reference checks on applicants prior to their hire date. This deficient practice was identified for; 17 of 185 employee files reviewed for employees hired on 10/3/24 or after. These deficient practices were evidenced by the following: A review of the facility-provided employee files revealed the following seven (7) employees were missing background checks prior to employment or date of hire and could not be provided by the facility:Employee #3 was hired on 2/1/25Employee #14 was hired on 1/13/25Employee # 15 was hired on 1/24/25Employee #16 was hired on 2/24/25Employee #17 was hired on 3/7/25Employee #19 was hired on 3/24/25Employee #21 was hired on 3/31/25 A review of the facility-provided employee files revealed the following seventeen (17) employees were missing reference checks prior to employment or date of hire and could not be provided by the facility:Employee #1 was hired on 2/26/25 Employee #2 was hired on 8/13/25 Employee #3 was hired on 2/1/25Employee #4 was hired on 2/17/25Employee # 5 was hired on 2/27/25Employee #8 was hired on 3/30/25Employee #9 was hired on 1/24/25Employee #11 was hired on 3/18/25Employee #12 was hired on 10/9/24Employee #14 was hired on 1/13/25Employee # 15 was hired on 1/24/25Employee #16 was hired on 2/24/25Employee #17 was hired on 3/7/25Employee #18 was hired on 3/20/25Employee #20 was hired on 3/24/25 rehire date from 11/14/22Employee #21 was hired on 3/31/25Employee #22 was hired on 2/1/25 On 3/18/26 at 9:52 AM, the surveyor interviewed the Human Resources Unit Clerk who stated that all the files and the contents had been given to the survey team. She does not have anything else to provide. On 3/18/26 at 10:08 AM, the surveyor interviewed the Human resource director, who stated background checks and references should be done prior to the employee start date to ensure the safety of the residents. On 3/19/26 at 11:53 AM, in the presence of the survey team, the Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA), and the Regional DON, the surveyor discussed the concerns regarding 24 of the 198 employee files reviewed that did not reflect documented evidence that the criminal background checks and reference checks were completed by the facility prior to the date of hire. The LNHA expressed the importance that reference checks and background checks. They are needed for the safety of the residents and his staff and to ensure the best employees are hired. A review of the facility-provided policy titled Abuse Prevention Program, revealed policy interpretation and implementation.Protect our residents from abuse by anyone including but not necessarily limited to facility staff.Conduct employee background checks. NJAC 8:39-9.3(b)

Based on interview, record review, and review of pertinent documents, it was determined that the facility failed to report an unwitnessed fall that resulted in a major injury to the New Jersey Department of Health (NJDOH) promptly for 1 of 2 residents (Resident #6) reviewed for investigations and was evidenced by the following:On 03/15/26 at 10:00 AM, the surveyor observed Resident #6 who was observed in bed that was set at the lowest position with two floor mats at the side of the bed.A review of the admission record (admission summary) reflected that Resident #6 was admitted to the facility with a diagnosis that included but not limited to spinal stenosis (the narrowing of the spinal canal, compressing nerves and causing back/neck pain, numbness, and leg weakness), major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest, and feelings of worthlessness lasting at least two weeks), and anxiety disorder (condition characterized by excessive, persistent fear or worry that interferes with daily life).A review of the quarterly Minimum Data Set, an assessment tool used to facilitate care, dated 01/21/26, reflected that the resident's cognitive skills for daily decision-making score was 3, which indicated that the resident was severely impaired.A review of a nursing progress note dated 3/01/26 at 20:02 (8:02 PM) revealed that the resident was found on the bathroom floor by a Certified Nursing Assistant (CNA) in a supine position (lying on one's back facing upward with legs extended and arms at the side). Upon assessment the resident was observed to have a large hematoma on the left side of the forehead. Area bruised, no active bleeding observed. Resident alert and responsive. No visible open are noted. Further assessment and VS (vital signs) obtained which are documented on neuro check sheet. MD and responsible party notified. Orders received and carried out as indicated. VS obtained: BP 161/93, HR: 112, RR 20, Temp 98F, O2 Sat 95%. Neuro checks initiated. MD notified ; order received for cold compress to affected area. Cold compress applied and Tylenol administered for pain. Family notified {redacted title} of incident and current condition. Family {titled redacted} requested resident be sent out to hospital for further evaluation. Order received to send resident to an acute care facility {name redacted} for CT (computed tomography ) scan.A review of a nursing progress note dated 03/02/26 at 06:44 (6:44 AM) revealed the following: Per hospital nurse, resident has been admitted to the Neuro Med Step-down unit. Diagnosis included a subdural hemorrhage and subarachnoid hemorrhage. Nurse reported that a repeat CT scan will be performed in six hours. If results are stable, resident may be discharged . If findings persist or worsen, resident will be formally admitted for continued management.A review of the facility Investigation Report titled Unwitnessed Fall dated 03/01/26 at 17:50 (5:50 PM) revealed the following: Resident was found lying supine on the bathroom floor by assigned CNA. Upon assessment resident noted having a large hematoma present to the left side of forehead. Purple/blue discoloration, no active bleeding observed. Resident alert and responsive. No visible opening is noted. Further assessment completed with no other injury noted at this time. VS and neuro checks obtained. MD and responsive party notified. Orders received and carried out as indicated. Resident Description: Resident unable to give description. A review of the New Jersey Universal Transfer Form dated 03/09/26 revealed that the resident was readmitted to the facility with a primary diagnosis of Subdural Hematoma.On 3/18/26 at 01:00 PM, the surveyor presented the above concerns to the facility administrative team which included the Director of Nursing (DON) and the Licensed Nursing Home Administrator. At that time, the surveyor requested the facility provide the surveyor with the reportable documentation that was sent to the state. The DON stated that the incident was not reported to the state because the injury resulted from a fall at the facility. The surveyor requested the facility policy addressing reporting or any documentation the facility would like to present.A review of the facility's policy for Abuse Investigation and Reporting that was dated 01/30/26 and was provided by the DON which revealed the following:Under Reporting: 2. Alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but not later than:Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury. On 03/19/26 at 11:00 AM, the surveyor reviewed the facility Abuse Investigation and Reporting Policy with the DON and LNHA in the presence of the survey team. The surveyor pointed out under the section titled Reporting which revealed that an alleged violation involving abuse or resulted in serious bodily injury should be reported within 2-hours. The surveyor presented to the facility administrative team the following: when you have an unwitnessed fall that resulted in a serious bodily injury (subdural hematoma) and hospitalization would this meet the facility criteria for reporting.No further information was provided. NJAC 8:39-4.1(a)5

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and facility policies and procedures for 1 of 18 residents, Resident #68, reviewed for quality of care. 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 case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 3/15/26 at 9:20 AM, the surveyor interviewed Resident #68 who was lying in bed. Surveyor observed resident's hearing aids on the nightstand not within reach of the resident and dentures in a container at bedside. Resident #68 stated the staff does not help with putting in the hearing aids or dentures. On 3/15/26 at 12:15 PM, the surveyor observed Resident #68 lying in bed, resident's dentures and hearing aids remain on bedside table and nightstand. Resident #68 stated they asked the Certified Nursing Assistant (CNA#1) for assistance but was not completed at that time.On 3/16/26 at 8:33 AM, the surveyor observed Resident #68 during lunch and the resident's dentures and hearing aids were not in place. On 3/16/26 at 9:15 AM, the surveyor reviewed the electronic medical chart (EMR) of Resident #68.The admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, multiple sclerosis(is an autoimmune disease that affects the central nervous system), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and tinea unguium (a fungal infection).A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/29/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #68 scored 15 out of 15, which indicated the resident had normal cognitive function. The MDS further indicated that Resident #68 wore hearing aids and was dependent on staff for oral hygiene.A review of Resident #68's care plan (CP) revealed a plan with the focus, Resident has upper and lower dentures and with interventions that included: Assist with placement of dentures in morning (am); remove at evening (hs). Resident #68 has an additional CP with a focus of, Resident has decreased function in all areas of activities for daily living (ADLs) and an intervention of, set up with all needed equipment for ADL care.On 3/16/26 at 9:45 AM, the surveyor interviewed CNA#1, who stated CNAs assist with oral care as needed including denture care, but cannot place hearing aids for the resident unless they have received specialized training, otherwise the resident's nurse will have to assist with placement. CNA#1 stated they were about to help Resident #68 with their dentures but did not remember if she had placed the dentures yesterday. On 3/18/26 at 9:05 AM, the surveyor interviewed Registered Nurse (RN#1) who stated nursing assists with placing the resident's hearing aids and CNAs assist with dentures. RN#1 stated she always assists Resident #68 with their hearing aids but does not normally work on the unit.On 3/18/26 at 10:00 AM, the Director of Nursing (DON) provided two facility policies. The Cleaning and Storing Dentures policy with a revised date 1/2024 revealed under the preparation and general guidelines, 1. Review the resident's care plan to assess for any special needs of the resident. Provide denture care before breakfast and at bedtime. The Care of Hearing Impaired Resident policy with a revised date 12/2025 revealed under the policy interpretation and implementation, 3. Staff will assist residents with care and maintenance of hearing devices.On 3/19/26 at 2:30 PM, the surveyor met with the DON and Licensed Nursing Home administrator (LNHA) to review concerns found during the survey. The DON stated all residents should have their dentures place before breakfast and taken out before bed, as well as all hearing devices should be in place after morning care.On 3/20/26 at 11:30 AM, the surveyor met with the DON, LNHA and Regional Registered Nurse (RRN) for exit conference. No further pertinent information provided.N.J.A.C. 8:39-3.2 (a), (b); 27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate treatment and care for a resident with an indwelling urinary catheter. The deficient practice was identified for 1 of 2 residents (Resident # 2) reviewed for urinary catheter care and was evidenced by the following:On 3/15/26 at 11:33 AM, the surveyor observed signage on Resident #2's door that indicated the resident was on Enhanced Barrier Precautions (infection control measures in nursing homes requiring staff to wear gowns and gloves during high-contact care). The surveyor observed Resident #2 in bed with a urinary catheter drainage bag contained in a privacy bag and affixed to the lower aspect of the resident's bed. The surveyor reviewed Resident #2's medical record. A review of the admission Record reflected that Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; diabetes mellitus (high blood sugar) and obstructive and reflux uropathy (blockage and back flow of urine toward the kidneys). A review of Resident #2's quarterly Minimum Data Set (MDS), an assessment tool dated 2/6/26, indicated that the resident's brief interview for mental status (BIMS) score was 15 of 15, indicating fully intact cognition. Section H reflected that the resident had an indwelling urinary catheter. A review of Resident #2's Care Plan included a focus area that the resident was at risk for infection requiring enhanced barrier precautions related to an indwelling urinary catheter with interventions that included but were not limited to; enhanced barrier precautions: use gown and gloves during high contact activities.Wound care, hygiene, toileting, transferring, bathing/showering .Perform hand hygiene prior to and after providing care to the resident. A review of Resident #2's current Order Summary Report (OSR) reflected active Physician's Orders (PO): Foley Catheter 16 French with 10CC balloon for neurogenic bladder (dysfunction in bladder control) dated 02/11/2026 and Irrigate the catheter (medical procedure that flushes sterile fluid into the bladder through a catheter to remove blood clots, sediment, or bacteria) with 60 cc Normal Saline (NSS) every shift for Catheter care dated 02/11/2026. On 3/16/26 at 1:25 PM, the surveyor observed the Licensed Practical Nurse (LPN) provide a procedure to Resident #2's urinary catheter. The surveyor observed the LPN, donned a disposable gown, washed his hands, turned off the sink with his bare hands, and applied gloves. The surveyor observed that the LPN placed the piston syringe and bottle of NSS on the resident's bed sheets. The LPN disconnected the urinary catheter port and, without disinfecting it with alcohol wipes, inserted the syringe tip into the port and irrigated (poured NSS) the tubing. The surveyor observed the LPN reconnected the tubing without disinfecting the port. On 3/18/26 at 2:50 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. On 3/19/26 at 10:00 AM, in the presence of the DON, the surveyor conducted a phone interview with the LPN and discussed the LPN's technique breaks in providing appropriate urinary catheter care. The LPN confirmed that he did not perform the procedure in accordance with acceptable standards of practice. The DON stated that she would provide education to the LPN. A review of the facility's Management of Indwelling Catheter policy reflected.A sterile closed drainage system should be used. The distal urinary catheter and proximal drainage tube should not be disconnected unless required for irrigation of obstructed catheter. Sterile technique should be used when collecting system is open and catheter irrigant fluid should be used and then discarded. Irrigation must be ordered by a physician. On 3/19/26 at 11:41 AM, no further information was provided. NJAC 8:39-19.1 (a); 19.4 (a) 5.

Based on interviews and review of pertinent documentation provided by the facility, and review of personnel files on 3/17/26, it was determined that the facility failed to check the multi-state registry upon hire for a Certified Aide (CNA) who had reciprocity. This deficient practice was identified for 3 of 59 newly hired CNAs, and was evidenced by the following:On 3/17/26 at 11:00 AM, the surveyor reviewed Employee #6's personnel file. The employee was hired by the facility as a CNA on 12/21/24. According to the CNA registry report, Employee #6 did not have reciprocity in the state of New Jersey (NJ).On 3/17/26 at 11:10 AM, the surveyor reviewed Employee #9's personnel file. The employee was hired by the facility as a CNA on 1/24/25. According to the CNA registry report, Employee #9 did not have reciprocity in the state of NJ.On 3/17/26 at 11:40 AM, the surveyor reviewed Employee #40's personnel file. The employee was hired by the facility as a CNA on 1/19/26. According to the CNA registry report, Employee #6 did not have reciprocity in the state of NJ.On 3/18/26 at 9:52 AM, the surveyor interviewed Human Resources Director/Unit Clerk (HR), who reviewed the employee records and confirmed CNA's #6, #9, and #40's CNA reciprocity was not present on their files.On 3/18/26 at 2:47 PM, the surveyor met with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) to review survey concerns. The LNHA acknowledged concerns with the employee files and stated there were on-going quality assurance program improvement (QAPI) for improvement.On 3/19/26 at 10:11 AM, the surveyor met with the DON, LNHA and the Regional Nurse. The LNHA stated that moving forward an in-service was conducted involving the DON. LNHA, Regional Nurse and HR discussed the pre-screening process requirements prior to start and CNAs #6, #9 and #40 were removed from the schedule until their reciprocity were provided and confirmed.On 3/19/26 at 12:30 PM, the surveyor met with the DON, LNHA and the Regional Nurse for exit conference. No further pertinent information provided. NJAC 8:39-43.1(a)(1)

Based on observation, interview and record review it was determined that the facility failed to ensure appropriate infection control practices were followed during wound care, including proper hand hygiene, use of personal protective equipment (PPE), maintenance of a clean field, and disinfection of equipment and environmental surfaces. This deficient practice was observed for 1 of 3 residents (Resident #2) reviewed for care and services for wound care and was evidenced by the following:Reference: Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces.CDC recommendations for Hand Hygiene: Updated February 27, 2024:https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html#cdc_clinical_safety_best_practices_recomm-recommendationsReference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.htmlOn 3/15/26 at 11:33 AM, the surveyor observed signage on Resident #2's door that indicated the resident was on Enhanced Barrier Precautions (Infection Control measures in nursing homes requiring staff to wear gowns and gloves during high-contact care). The surveyor observed Resident #2 in bed.The surveyor reviewed Resident #2's medical record.A review of the admission Record reflected that Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; diabetes mellitus (high blood sugar), glaucoma (high eye pressure leading to irreversible, gradual, or sudden vision loss) and obstructive and reflux uropathy (blockage and back flow of urine toward the kidneys).A review of Resident #2's quarterly Minimum Data Set (MDS), an assessment tool dated 2/6/26 reflected that the resident's brief interview for mental status (BIMS) score was 15 of 15 which indicated a fully intact cognition. Section M indicated the resident's skin was intact. A review of Resident #2's Care Plan included a focus area that the resident was at risk for infection requiring enhanced barrier precautions with interventions that included but were not limited to; Enhanced barrier precautions: use gown and gloves during high contact activities.Wound care, hygiene, toileting, transferring, bathing / showering .Perform hand hygiene prior to and after providing care to resident. A review of Resident #2's current Order Summary Report (OSR) reflected a Physician's Order (PO): Vascular consult r/t wounds to the left foot toes/plantar foot dated 02/28/2026; PO left third toe venous leg ulcer (VLU) paint with betadine, apply Calcium Alginate, Abdominal (ABD) pad, and secure with a Kling dressing wrap every day shift with a 03/04/2026.On 3/16/26 at 1:05 PM, with the resident's permission, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment to Resident #2's vascular wound located on the 3rd toe of the resident's left foot.The LPN gathered the supplies which included a sterile, absorbent 2x2 calcium alginate dressing (designed to keep the wound moist for faster healing), betadine swab stick (used to clean the wound), Kling wrap (stretchy bandage to secure the dressing in place). The surveyor observed the LPN donned (put on) a disposable gown; however the gown was not secured at the neck or the waist. The LPN placed the wound care supplies on the resident's dresser, which contained personal items including a hairbrush, beverage cans, surgical masks and picture frames, without first disinfecting the surface or applying a clean barrier.The LPN removed gloves, washed hands and turned off the faucet using his bare hands, stating that no paper towels were available. The LPN shook his hands to dry them and while hands were still wet, donned a new pair of gloves.The LPN then transferred the supplies from the dresser to the overbed table without disinfecting the table prior to use.During the procedure, the LPN removed the resident's heel protector and stated that scissors were needed. The LPN removed gloves, opened the door to the hallway, and accessed the treatment cart while wearing the same unsecured gown. The LPN retrieved the scissors and used them to cut and remove the existing dressing without disinfecting them.The LPN repeatedly removed gloves, performed hand hygiene, and turned off the faucet using bare hands. The LPN did not adequately dry his hands prior to donning new gloves, instead shaking them and applying gloves while hands remained wet. The surveyor observed that the LPN's gown was loose and repeatedly came into contact with the sink and the resident's bed.The LPN applied betadine to the wound with a swab stick, applied the calcium alginate, ABD pad and Kling wrap. A 4x4 silicone dressing was then applied. The surveyor observed that the LPN with the same gloved hands, reached under the disposable gown into his pocket to retrieve a marker and wrote directly on the resident's bandage, rather than labeling the tape prior to the application. After completing the wound treatment, the LPN removed his gloves and gown, performed hand hygiene, again turning off the faucet with bare hands, shook hands dry, and donned a new gown and gloves. The LPN stated, I should have tied the last gown, but I didn't. I guess I will do it now.The LPN then stated that he needed to wash the scissors. The LPN applied hand soap to the scissors and placed them under the stream of running water without evidence of appropriate disinfection. On 3/16/26 at 1:30 PM, the surveyor discussed the breaches in infection control practices observed during the wound treatment with the LPN. The LPN acknowledged the breaches. On 3/18/26 at 2:50 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing.A review of the facility's Wound Care: Treatment Administration policy dated 1/2026 reflected .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Steps in the procedure .Use disposable cloth to establish clean field on resident's overbed table .place all items to be used during procedure on the clean field .Mark tape with initials, time, and date, and apply to the dressing. Be certain all clean items are on the clean field. Use clean field saturated with alcohol to wipe overbed table. Wipe reusable supplies with alcohol as indicated i.e. Scissors . A review of the facility's Wound Care Observation Checklist for Infection Control dated 9/2022 reflected clean field prepared:Hand hygiene performed by CDC standards before preparing clean fieldClean field prepared; surface cleaned with antiseptic wipes following manufacturers guidelines.Surface barrier applied (e.g. chux pad)Supplies placed on surface barrier in aseptic mannerClean gloves and Personal Protective Equipment (PPE) donned according to standards or contact precautionsReusable equipment cleansed and disinfected appropriately ex table surfaceThe facility was unable to provide the surveyor with a completed copy of the LPN's Wound Care Observation Checklist for Infection Control.A review of the facility's Rehab & Nursing policy reflected .Proper hand hygiene is that which occurs at the right time, uses the right method, and uses correct technique and duration.When washing your hands with soap and water, rub hands together vigorously for at least 20 seconds covering all hand surfaces. Rinse hands with water, use disposable towels to dry, and turn off the faucet with separate paper towel. On 3/19/26 at 11:41 AM, no further information was provided by the facility.NJAC 8:39 - 19.4(a)(n); 27.1 (a)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and correct diet consistency was followed for 3 of 5 residents (Resident #8, #19, and #51) reviewed for dietary preferences. This deficient practice was evidenced as follows: 1. On 9/26/24 at 08:35 AM, the surveyor observed Resident #8 in their room, awake in bed. During the interview, Resident #8 stated their meal trays are usually missing items and/or have incorrect items. Resident #8's breakfast tray arrived during the interview. Resident #8's breakfast ticket stated the resident was on a regular diet with a ground consistency (ground consistency are food that should be soft, moist, and cohesive in texture. Meats should be finely chopped, and vegetables should mash easily with a fork.) The surveyor observed Resident #8's tray were missing a 4 ounce (oz) pureed fruit cup and a 4 oz apple/cran-orange juice as indicated in their meal ticket. The surveyor further observed a piece of coffee cake in a ground consistency. As indicated in the meal ticket, the coffee cake should be served in a pureed consistency (pureed consistency is all food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding). The certified nursing assistant #1 (CNA #1), called the kitchen to request for the missing items on the resident's tray and clarified what was the consistency of the coffee cake the resident should receive. A review of the Admission Record (an admission summary) (AR) reflected that the resident was admitted with diagnoses that included but were not limited to; Dysphagia, need for assistance with personal care and muscle weakness. A review of the Quarterly Minimum Data Set (MDS), a tool used to facilitate the management of care, dated 9/10/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that Resident #8 was cognitively intact. A review of the September 2024 Physician's Orders (PO) included a PO dated 7/1/24 for a Regular diet, ground texture, thin liquid. A review of Resident #8's Nutrition progress note form dated 9/26/24 at 8:30 AM, reflected that the Registered Dietitian (RD) documented Food preferences: no new preferences at this time. Specific food preferences were not indicated within the assessment. 2. On 9/26/24 at 8:55 AM, the surveyor observed Resident #19 who was in their bed and awake. The resident stated their meal trays are frequently missing some items that they had specifically requested. The surveyor observed, Resident #19's breakfast tray, the breakfast ticket stated the resident is on a Regular diet, regular texture, and thin liquids. The surveyor observed Resident #19's tray was missing a 4 oz cranberry juice. Resident #19 stated they were supposed to receive cranberry juice with each meal. On 9/26/24 at 12:55 PM, the surveyor observed Resident #19's lunch meal tray that didn't have the 4oz cranberry juice was missing. A review of the AR reflected Resident #19 was admitted to the facility with diagnoses that included but were not limited to; Multiple Sclerosis, Vitamin B deficiency and Tinea Unguium. A review of the Quarterly MDS, a tool used to facilitate the management of care, dated 8/27/24, indicated that the resident had a BIMS score of 15 out of 15, which reflected that the resident was cognitively intact. A review of the September 2024 PO included a PO dated 6/1/24 for a Regular diet, regular texture, thin liquid. A review of Resident #19's Nutrition progress note dated 7/5/24 at 8:30 AM, reflected that the Registered Dietitian (RD) documented The resident would also like ginger ale and cranberry juice each meal, reported to FSD (food service director). A review of Resident #19's nutrition care plan dated 7/15/24, under interventions and tasks stated, Provide me with my food/beverage preferences. 3. On 9/26/24 at 9:03 AM, the surveyor observed Resident #51 awake in their bed. Resident #51 stated, they had to call the kitchen almost every meal for the missing items in their meal tray. The surveyor observed the breakfast served to the resident on the same day. The meal ticket stated the resident was on a consistent carbohydrate (CCD), no added salt (NAS) diet, Regular texture, thin Liquids consistency. The surveyor observed Resident #51's tray was missing a 4-ounce (oz) prune juice. A review of the AR indicated that Resident #51 was admitted to the facility with diagnoses that included but were not limited to; Heart Failure, Muscle Weakness and Tinea Unguium. A review of the Annual MDS, a tool used to facilitate the management of care, dated 9/3/24, revealed that the resident's BIMS was not completed due to the resident's interview was not able to be conducted at that time. A review of the September 2024 PO included a PO dated 4/2/24 for a CCD/NAS diet, regular texture, thin liquid. A review of Resident #51's Nutrition Progress note dated 8/7/24, reflected that the Registered Dietitian (RD) documented noted order for prune juice in the morning for prevention of constipation. A review of Resident #51's nutrition care plan dated 7/5/24, under interventions and tasks stated, Provide and serve diet as ordered. On 9/27/24 at 9:46 AM, the surveyor interviewed the Food Services Director (FSD) who stated, they were not aware of the missing items on the resident's trays and weekly tray audits were completed by the FSD together with the RD. The FSD also stated Resident #8 was served the correct consistency coffee cake, but unable to provide information as to why the tray ticket stated pureed. On 9/30/24 at 12:41 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Tray identification/Accuracy policy with a revision date of 4/24/24. Under the policy interpretation and implementation, it states, 1. To assist in setting up and serving the correct food trays/diets to residents, the food Service Department shall use appropriate identification (e.g., color coded or computer-generated diet cards) to identify the various diets. 2. The Food Services manager or supervisor shall check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. 4. If there is an error, the Nurse Supervisor shall notify the Dietary Department immediately by phone so that the appropriate food tray can be served. On 9/30/24 at 1:16 PM, the surveyor interviewed the FSD, who stated the kitchen staff placed pitchers of juice on the tray carts that goes to the nursing units to be served. The FSD further stated that the nursing staff on the units were supposed to pour the juices into the cups and pass them out to the residents. On 9/30/24 at 1:33 PM, the survey team met with the LNHA and Director of Nursing to discuss the above concerns. The LNHA stated the missing tray items were not acceptable. There were no further information provided. NJAC - 17.4(a)1, (e)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner that would prevent food borne illnesses. This deficient practice was observed and evidenced by the following: On 9/25/24 at 09:41 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. The juice dispensing machine was observed with 3 of 6 juice plastic tubes that lead from the juice concentrate to the juice dispenser, with a sticky substance covering the tubes. The FSD stated the tubing should always be clean and free of any debris. 2. In walk-in refrigerator #1, the surveyor observed the fans, fan grates and panels with a dark colored dust like debris. 3. In the walk-in freezer, the surveyor observed large ice and frost build up on the fans, walls, and ceiling. The FSD could provide an information why the frost build up occurred. On 9/26/24 the Licensed Nursing Home Administrator (LNHA) provided the surveyor with two undated facility policies, titled, Dietary Cleaning and Food Storage The dietary cleaning policy stated under the procedure section, I. The dietary manager will develop a cleaning schedule that includes the frequency of which equipment, and areas will be cleaned. A. The cleaning schedule will be posted weekly. B. The cleaning schedule includes tasks assigned to specific positions within the dietary department. C. Dietary staff will initial next to the assigned task once it is completed. The dietary manager monitors the cleaning schedule to ensure compliance. The LNHA also provided a blank copy of the weekly deep cleaning list which included the tasks of cleaning the freezers and refrigeration. The FSD and LHNA unable to provide the most recent copy of the weekly deep cleaning list. On 9/30/24 at 1:33 PM, the survey team met with the LNHA and Director of Nursing to discuss the above concerns. There were no further information provided. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) for one (1) of 18 residents (Resident #75) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: On 09/25/24, at 10:20 AM, the surveyor observed Resident #75 in their room seated in bed wearing a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) (NC) connected to an oxygen (O2) concentrator at three (3) lpm which reflected on the O2 regulator. On 09/26/24 at 10:19 AM, the surveyor reviewed Resident #75's electronic medical record, which revealed the following information: The resident's Admission Record (an admission summary) revealed that Resident #75 was admitted with diagnoses that included but were not limited to Respiratory failure unspecified by Hypoxia (lack of oxygen). The Quarterly Minimum Data Set (Q/MDS), dated [DATE], indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status score of 15 out of 15, which indicated that the resident was cognitively intact. Further review of the Q/MDS under Section O Special Treatments, Procedures, and Programs C1. Oxygen therapy B. While a Resident was coded Yes. A review of the September 2024 Order Summary Report (OSR) revealed the following Physician's Order (PO) dated 05/15/24 for O2 at 2 lpm continuously via NC to maintain O2 saturation above 92% every shift. Further review of the September 2024 OSR revealed a PO for Restorative Nursing Program (RNP) dated 07/04/24 to perform passive range of motion (PROM) exercise to both lower extremities (BLE) as tolerated. The above PO for O2 administration was transcribed to the September 2024 electronic Medication Administration Record and was signed by the nurses which indicated that the O2 was administered to the resident every shift. A review of Resident #75's comprehensive person-centered CP did not reflect the resident's use of continuous O2 and for the RNP exercises. On 10/01/24 at 09:40 AM, the surveyor interviewed the Director of Rehabilitation/Occupational Therapy (DOR/OT), who confirmed that the resident had a PO for PROM exercise to BLE. On 10/01/24 at 09:57 AM, the surveyor team met with the Licensed Nursing Home Administrator and the Director of Nursing to discuss the above concern. There was no further information provided. A review of the facility policy titled Care Plans, Comprehensive, Person-Centered with a revision date of 1/2024 reflected under: Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Policy Interpretation and Implementation, k. Reflect treatment goals, timetables, and objectives in measurable outcomes; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program. NJAC 8:39-11.2(e) thru (i); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 2 of 2 residents (Resident #30 and #75) reviewed for Oxygen use. This deficient practice was evidenced by the following: 1. On 09/25/24 at 11:35 AM and on 09/26/24 at 11:30 AM, the surveyor observed on both days that Resident #30 was lying in bed, wearing a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) (NC) connected to an oxygen (O2) concentrator at two (2) liters per minute (lpm) on the regulator. On 09/25/24 at 12:01 PM, the surveyor reviewed Resident #30's electronic medical record, which revealed the following information: The resident's Admission Record (an admission summary) (AR) documented that Resident #30 was admitted with diagnoses that included but were not limited to unspecified Dementia (impairment of memory). The Annual Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care dated 06/25/24, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of zero (0) out of 15, which indicated that the resident had severely impaired cognition. Further review of the A/MDS Section O Special Treatments, Procedures, and Programs C1. Oxygen therapy B. While a Resident was coded Yes. A review of the September 2024 Order Summary Report (OSR) revealed an active Physician Order (PO) with an order date of 09/03/24 for oxygen at three (3) lpm continuously via NC to maintain O2 saturation above 92% every shift. The above PO for O2 was transcribed to the September 2024 electronic Treatment Administration Record (eTAR) and was signed by nurses indicating O2 was administered to Resident #30 every shift. On 09/26/24 at 12:17 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) checked and confirmed that the O2 was set at 2 lpm from the concentrator regulator. The LPN checked the eTAR and confirmed to the surveyor that the oxygen PO was at 3 lpm via NC. 2. On 09/25/24, at 10:20 AM, the surveyor observed Resident #75 inside their room seated in bed wearing an NC connected to an O2 concentrator at three (3) lpm set on the regulator. On 09/26/24 at 12:25 PM, the surveyor observed Resident #75 seated in a wheelchair inside the dining room having their lunch. The surveyor observed Resident #75 receiving O2 via NC at one (1) lpm connected to a portable O2 tank. The LPN confirmed to the surveyor that the resident was receiving 1 lpm of oxygen via NC. On 09/26/24 at 10:19 AM, the surveyor reviewed Resident #75's electronic medical record, which revealed the following information: The resident's AR documented that Resident #75 was admitted with diagnoses that included but were not limited to respiratory failure unspecified by hypoxia (lack of oxygen). The Quarterly Minimum Data Set (Q/MDS), dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 15 out of 15, which reflected that the resident was cognitively intact. Further review of the Q/MDS Section O Special Treatments, Procedures, and Programs C1. Oxygen therapy B. While a Resident was coded Yes. A review of the September 2024 OSR revealed an active PO with an order date of 05/15/24 for oxygen at 2 lpm continuously via NC to maintain O2 saturation above 92% every shift. The above PO for O2 was transcribed to the September 2024 electronic Medication Administration Record (eMAR) and was signed by nurses as administered every shift. On 10/01/24 at 09:57 AM, the survey team met with the Licensed Nursing Home Administrator, and Director of Nursing. There were no further information provided. The facility policy titled Oxygen Administration with a revision date of 1/2024 under Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. NJAC 8:39-25.2(c)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 4 (four) residents (Resident #61) observed during the medication observation pass. The 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 case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 09/30/24 at 8:45 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse #1 (LPN#1) in the room of Resident #61. The surveyor observed LPN #1 checking the resident's identification bracelet and informed Resident #61 that she would be administering the resident's medications. On 09/30/24 at 8:50 AM, the surveyor observed LPN #1 preparing to administer six (6) medications to Resident #61 which included the following, Norvasc 2.5 mg tablet (medication for lowering blood pressure), Baclofen 10 mg tablet (medication for muscle spasms),Buspar 5 mg (medication for anxiety), Cranberry 450 mg (medication to prevent UTI), Eliquis 5 mg (medication for thinning blood and Flomax 0.4 mg capsule (medication for enlarged prostate). The surveyor observed LPN #1 crushed the Norvasc, Baclofen, Buspar, Cranberry and Eliquis and then adding the crush contents into a medication cup and mixed the contents with apple sauce. The surveyor further observed LPN #1 who opened the Flomax capsule and emptying the contents of the capsule into the apple sauce that contained all the other crushed medications. The surveyor observed LPN#1 administered the medications to Resident #61. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to Hypertension (elevated blood pressure), Benign Prostatic Hyperplasia (Prostate enlargement), and Anxiety Disorder (a mental health disorder characterized by feeling worried, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 7/23/24, reflected that the resident's cognitive skills for daily decision-making score was 13 out of 15, which indicated that the resident's cognition was cognitively intact. A review of the September 2024 Order Summary Report (OSR) revealed a PO dated 10/18/23, for Flomax Capsule 0.4 mg (Tamsulosin HCL) give 1 capsule by mouth two times a day for benign prostatic hyperplasia. Administer 30 minutes after meal. Do Not Crush, open or chew. Swallow capsules whole with water. A review of the September 2024 electronic Medication Administration Record (eMAR) revealed an order dated 10/18/23, for Flomax Capsule 0.4 mg (Tamsulosin HCL) give 1 capsule by mouth two times a day for benign prostatic hyperplasia. Administer 3 minutes after meal. Do Not Crush, open or chew. Swallow capsule whole with water. On 9/30/24 at 11:45 AM, the surveyor in the presence of LPN #1 reviewed Resident #61's physician's orders. After reviewing the resident's PO for Flomax, the surveyor interviewed LPN #1, who acknowledged that the resident's Flomax should have not been opened and that she should have administered the medication whole with water. On 9/30/24 at 1:30 PM, the surveyor discussed the above concern with the Licensed Nursing Home Administrator and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for Administering Medication dated 6/19/23, which was provided by the DON included the following: Medications must be administered in accordance with the orders, including the required time frames. NJAC 8:39-11.2 (b), 29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store, and dispose of medications in two (2) of four (4) medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 10:15 AM, the surveyor inspected the first-floor medication cart #2 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened vial of Lantus insulin with an opened date of [DATE] and was expired. At that time, the surveyor interviewed LPN#1 who acknowledged that Lantus Insulin vial which was opened on [DATE] and was expired. She stated to the surveyor that Lantus insulin once opened had a 28-day expiration date. On [DATE] at 10:25 AM, the surveyor inspected the 1st floor medication cart #1 in the presence of LPN#2. The surveyor observed an unopened bottle of Xalatan eye drops (medication for pressure in the eye) that was not dated and was stored in the medication cart and an opened vial of Lantus insulin that contained no opened date. At that time, the surveyor interviewed LPN#2 who acknowledged that the opened bottle of Xalatan eye drops should have been stored in the medication refrigerator. LPN #2 also acknowledged that once the Lantus insulin was removed from the refrigerator, it should have been dated. On [DATE] at 11:45 AM, the surveyor inspected the 2nd floor medication cart #2 in the presence of LPN#3. The surveyor observed an opened bottle of Timolol eye drops (medication for pressure in the eye) that was dated [DATE] and was expired. At that time, the surveyor interviewed LPN#3 who stated that the Timolol eye drops were expired and that it should have been removed from the medication cart. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Lantus insulin vial once opened has an expiration date of 28-days. 2. Unopened Xalatan eye drops once opened should be stored in the refrigerator 3. Timolol eye drops once opened has an expiration date of 28-days. On [DATE] at 1:30PM, the surveyor discussed the above concerns to the Licensed Nursing Home Administrator and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy titled Storage of Medications dated [DATE] and provided by the DON included the following: 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 5. Medications requiring refrigeration must be stored in a refrigerator in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. NJAC: 8:,d+[DATE].4 (a) (h) (d)

Based on observation, interview, and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for one (1) of 18 residents (Resident #71) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: On 09/25/24 at 11:05 AM, the surveyor observed Resident #71 seated in bed with the indwelling catheter (closed sterile system with a catheter and retention balloon that is inserted either through the urethra or suprapubically to allow for bladder drainage) inside a privacy bag, draining yellowish urine. The resident was able to respond to surveyor's inquiry. On 09/30/24 at 09:35 AM, the surveyor reviewed Resident #71's electronic medical record, which revealed the following information: The resident's Admission Record (an admission summary) (AR) documented that Resident #71 was admitted with diagnoses that included but were not limited to Neuromuscular Dysfunction of the bladder unspecified (inability to control when to urinate). The Admission MDS (A/MDS), dated [DATE], indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which stated that the resident had intact cognition. Further review of the A/MDS Section H Appliances C. Ostomy (including urostomy, ileostomy, and colostomy) was coded Yes. A review of the Order Summary Report from July 2024 does not reflect ostomy care (managing a surgical opening created in the body to redirect waste when the digestive or urinary system is damaged including, colostomy, ileostomy and urostomy). A review of Resident #71's person-centered interdisciplinary care plan does not reflect that the resident had a urostomy, ileostomy, or colostomy. A review of the Physician's Progress Notes (PPN) dated 7/22/24 does not reveal the resident had a urostomy, ileostomy, or colostomy in the assessment. A review of nursing progress notes from 7/19/24 to 7/25/24 did not reflect documentation that the resident has a urostomy, ileostomy, or colostomy. On 09/30/24 at 10:55 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN), who stated it was a coding error when she indicated that the resident had ostomy. The MDSC/RN also added that the resident had no previous history of presence of ostomy documentation in the medical records. According to the CMS (Centers for Medicare & Medicaid Services) MDS 3.0 RAI (Resident Assessment Instrument) Manual of October 2024, The RAI manual revealed under Version 3.0 Manual, page H-3, under H0100: Appliances (Cont.) Suprapubic catheters and nephrostomy tubes should be coded as an indwelling catheter (H0100A) only, not as an ostomy (H0100C). Further review of the A/MDS, dated [DATE], revealed under Section O0250. Influenza vaccine A. Did the resident receive the influenza vaccine in this facility for this year's Influenza vaccination season? Was coded -Not assessed/no information. C. If influenza vaccine not received, state reason: and was coded -Not assessed. And Section O0300. Pneumococcal vaccine A. Is the resident's Pneumococcal vaccination up to date? was coded -Not assessed/no information. C. If pneumococcal vaccination not received, state reason: and was coded -Not assessed. On 09/25/24 at 11:05 AM, the surveyor interviewed Resident #71, who stated that they received the influenza vaccination yearly but could not recall the date when he received the pneumonia vaccination. On 09/30/24 at 11:53 AM, the surveyor interviewed the facility's Infection Preventionist (IP). The IP stated that Resident #71 had history of receiving Influenza and Pneumonia vaccine five years ago. The IP also stated they obtained a consent from the resident to receive the Influenza vaccine. The resident refused to get a pneumonia vaccine. A review of the immunization record revealed the following: PCV-20 Consent Required, Influenza vaccine, quadrivalent, adjuvanted Consent Required, Moderna's Spikevax Vaccine 24-25 Consent Required. On 09/30/24 at 10:55 AM, the surveyor interviewed the MDSC/RN, who stated that one of the processes of gathering assessment was through interview of the resident or family members. The MDSC/RN also stated that she does not remember why the data was not assessed or no information for both influenza and pneumonia vaccines. The MDSC/RN stated they followed the RAI Manual. According to the CMS (Centers for Medicare & Medicaid Services) MDS 3.0 RAI Manual of October 2024, The RAI manual revealed under Version 3.0 Manual, page O-12, under O0250: Influenza Vaccine. Steps for assessment 2. Ask the resident if they received an influenza vaccine outside the facility for this year's influenza vaccination season. If vaccination status is still unknown, proceed to the next step. On page O-16, under O0300: Pneumococcal Vaccine. Steps for assessment 2. Ask the resident if they received any pneumococcal vaccines outside of the facility. If the vaccination status is still unknown, proceed to the next step. On 10/01/24 at 09:57 AM, the survey team met with the Licensed Nursing Home Administrator and the Director of Nursing to discuss the above concerns. There was no further information provided. NJAC 8:39-33.2(c)2, (d)

Complaint # NJ00164623 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was free of significant medication errors regarding the administration of anti-anxiety medication in accordance with the physician's order to prevent an adverse outcome for Resident #390. The facility failed to ensure that nurses administered medication to Resident #390 in accordance with professional standards of nursing practice. The significant medication errors were administered by two different nurses on three different days on 5/27/23, 5/29/23, and 5/30/23 when the anti-anxiety medication Klonopin was administered more than quadruple the prescribed medication dosage on each day to Resident #390 that resulted in the resident experiencing serious adverse effects of low blood pressure (less than 90/60 mmHg [milliliters of mercury]), increased congestion, pale, and hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) resulting in an acute change of condition with a sudden clinically deviation from the resident's baseline. This deficient practice was identified for 1 of 3 residents reviewed who were on Clonazepam (Klonopin), and was evidenced as follows: A review of the manufacturer's specifications for Klonopin included the following: WARNING: RISKS FROM CONCOMITANT USE WITH OPIOIDS; ABUSE, MISUSE, AND ADDICTION; and DEPENDENCE AND WITHDRAWAL REACTIONS Concomitant use of benzodiazepines (depressant drugs) and opioids (controlled substances used to treat moderate to severe pain) may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs for patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation (see WARNINGS and PRECAUTIONS). Geriatric Use . In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy . Sedating drugs may cause confusion and over-sedation in the elderly; elderly patients generally should be started on low doses of Klonopin and observed closely. Precautions; General, Psychiatric and Paradoxical reactions (an effect of a chemical substance, such as a medical drug, that is opposite to what would usually be expected), such as agitation, irritability, aggression, anxiety, anger, nightmares, hallucinations, and psychoses are known to occur when using benzodiazepines . Paradoxical reactions are more likely to occur in children and the elderly. Overdose Management Treatment includes monitoring of respiration, pulse, and blood pressure, general supportive measures . On 7/25/23 at 10:42 AM, the surveyor reviewed the closed medical record of Resident # 390. The Admission Record (admission summary) reflected that the resident was admitted with diagnoses that included Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), unspecified dementia (loss of cognitive functioning), bipolar disorder (mental illness that causes unusual shifts in mood from extreme high to extreme low), dysphagia (difficulty swallowing), peripheral vascular disease (circulation disorder), major depressive disorder (persistent feeling of sadness and loss of interest) and generalized anxiety disorder. A review of the most recent Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, dated 5/04/23, reflected that the resident had a brief interview for mental status (BIMS) score of six (6) out of 15, which indicated the resident had a moderate to severely impaired cognition. Further review of the CMDS section E for Behavior revealed that the resident was not delusional and section N for Medications reflected the resident received antipsychotic and anti-anxiety medications during the look-back period. The resident's individualized care plan with a revised date of 8/03/22, under the section for intervention/tasks included to review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics (medication that blocks a type of neurotransmitter), opioids (addictive medications typically used for pain), benzodiazepines (depressants) recent discontinuation, omission or decrease in the dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. A review of the Psychiatric Progress Note (PN) dated 3/24/23 revealed recommendations that included but were not limited to the discontinuation of an order for an as needed (PRN) dose of Klonopin PRN and an increase in the frequency of the routine Klonopin from 0.5 milligrams (mg) twice daily to Klonopin 0.5 mg three times daily (every eight hours) for anxiety. The Social Services Note dated 3/28/23 indicated that the order for the as needed Klonopin was discontinued, and the routine standing order for the Klonopin was increased (in frequency) to 0.5 mg every eight hours. The Physician Monthly PN dated 4/06/23, under Assessment and Plan, included the following: Alzheimer's dementia with behavior disturbance -gets agitated at times due to anxiety and yells out but improved now with med [medication] changes by psych (psychiatrist), followed by psych, monitor depression/anxiety improved with med changes by psych, psych f/u [follow-up] monitor -stable with meds . A review of the Order Recap Report (ORR) for 5/2023, included the following physician orders: -Clonazepam (Klonopin) Oral Disintegrating tablet (ODT) 1 (one) mg dated 3/27/23. The order indicated to give one tablet by mouth three times a day. It further specified to give two tablets (tabs) of 0.5 mg to total the 1 mg dose related to generalized anxiety disorder. The order summary report indicated that this physician order was discontinued on 5/16/23. The ORR for 5/2023 reflected a new physician order for Klonopin dated 5/16/23 to administer Clonazepam (Klonopin) ODT 1 mg, give one tab by mouth three times a day, related to generalized anxiety. The surveyor reviewed a Controlled Drug Record (CDR; a declining inventory log used for the accountability for controlled drugs) which revealed a pharmacy provider label for, Clonazepam ODT 0.25 mg, give four tablets by mouth three times a day for Resident #390. The CDR was signed by a nurse indicating that 90 tablets of 0.25 mg were delivered on 5/18/23. A review of a second Controlled Drug Record revealed a pharmacy provider label for Clonazepam ODT 1 (one) mg. The CDR revealed that the Pharmacy Provider now delivered 1 mg tablets instead of 0.25 mg tablets. The label indicated to give 1 mg tablet by mouth three times a day and was signed as received on 5/27/23 by LPN #3 for 60 doses. Further review of the second CDR reflected the following: -5/27/23 at 9:00 PM, 4 (four) tablets [total of 4 mg, instead of 1 mg per order] of Klonopin were removed from the inventory for administration by LPN #1. -5/28/23 at 6:00 AM, 4 (four) tablets [total of 4 mg, instead of 1 mg per order] of Klonopin were removed from the inventory for administration by LPN #1. There were no tablets of Klonopin signed as wasted. The electronic Medication Administration Record (eMAR) for May 2023 revealed the following: -5/27/23 at 9:00 PM was signed as administered by LPN #1. -5/28/23 at 6:00 AM was signed by LPN#1 as the drug was refused. 1. A review of Resident #390's Medication Error Incident Report ([NAME]) dated 5/29/23 signed by the Director of Nursing (DON) included the following: Date of Error: 5/27/23 at 9:00 PM Date of Error Discovery: 5/29/23 at 8:36 AM Medication/Treatment involved: Klonopin Type of Error: Incorrect dose Explanation/Reason medication error was made, reflected Resident was previously receiving 0.25 mg tabs [tablets] (4 to equal 1 mg) and the new bingo card was delivered with 1 (one) mg tabs and nurse subsequently gave 4 (four) without confirming the right dose. Actions Taken: Resident assessed. Medical Doctor (MD) made aware. The family was made aware. Nurse written up and educated. The [NAME] also revealed that on 5/27/23, Licensed Practical Nurse#1 (LPN #1) administered the incorrect dose to the resident because the dosage of the tabs had changed, and the nurse failed to perform a dose check prior to administration. LPN #1 was informed via telephone by the DON on 5/30/23. No employee comment was annotated. A review of the Incident Report (IR) dated 5/29/23 at 9:40 AM, revealed the following: Incident Description: On 5/27/23 around 9:00 PM, the resident was given 4 (four) mg of Klonopin instead of 1 (one) mg as prescribed. The resident previously had a plastic bag of 0.25 mg disintegrating tabs therefore the nurses were giving 4 (four) tabs to equal 1 (one) mg. However, a new bag of tabs had been delivered 1 (one) mg tabs and the nurse failed to complete the five rights of medication pass, subsequently administering 4 (four) tabs of the 1 (one) mg tab for a total of 4 (four) mg, instead of total 1 (one) mg. Because they are disintegrating tabs, they do not come in a bingo card and are delivered in blister packs in a small plastic bag so the nurse should have checked the back of the blister pack for the correct dosage. The IR included that the resident unable to give a description. Further review of the IR, under Immediate Action Taken, revealed: Resident did suffer some adverse effects although this was not recognized until hindsight as the error was committed on 5/27 and was subsequently identified on 5/29. However, on 5/28, resident was pale with increased congestion, as well as hypotensive (lowered blood pressure) and hypoxic. Resident was lethargic most of the day with lack of appetite. MD was made aware at this time with no new orders as resident is on hospice. HOB (head-of-bed) was elevated, 02 at 1.5 L (liters) via NC (nasal cannula) was applied, resident suctioned. Resident later stabilized. MD and family were made aware of Klonopin mistake on 5/29/23 with no new orders from MD. A review of Resident #390's PN included the following: On 5/28/21 at 5:21 AM, LPN #1 documented that Resident #390 was noted to be pale, cool to touch, crying out, O2 (oxygen) sat [saturation] 78% placed on 1.5 L (liters) of oxygen for comfort, BP [blood pressure] 78/42, pulse 94. Resident #390 is a DNR (do not resuscitate; does not want other life-saving measures in the event of cardiac arrest)/DNI (does not want to be placed on a ventilator), on hospice. Attempted to give 6:00 AM dose of Klonopin but resident refused. Repositioned for comfort and covered with extra blankets. Will continue to monitor. On 5/28/23 at 7:34 AM, LPN #2 documented that Placed a call to [name redacted] hospice, updated nurse regarding a change in condition (deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) from the previous shift. Comfort orders received, Levsin [an anti-tremor medication] 0.125 mg, 1 (one) tab sl (sublingually) q 4 h (every 4 hours), secretion. Morphine Sulfate (a narcotic medication also known as an opioid) 100 mg/5 ml (milliliter), give 0.25 ml q 2 h (every 2 hours) for pain or shortness of breath. On 5/28/23 at 8:42 AM, LPN #2 documented: Place a call to MD [medical doctor] made aware of change in condition, increase congestion and secretion, hospice made aware and will contact family. On 5/29/23 at 8:18 AM, (reflected late entry) LPN #2 documented: Medication error noted on 5/27 in reference to Klonopin. Dr [Name Redacted] made aware and no new orders at this time, and POA [Power of Attorney] made aware. On 5/29/23 at 3:15 PM, Registered Nurse #1 (RN #1) documented: Patient did not eat for breakfast, lunch only drank orange juice, [brand redacted] protein supplement, PRN sublingual Levsin, SO2 93% via NC (nasal cannula) T (temperature 97.3) . A review of the Licensed Nurse Competency Checklist for LPN #1 did not include a Medication Pass Observation. A review of the facility In-Service (education); The five rights of medication pass, dated 5/29/23 did not include LPN #1. A review of the undated, facility provided In-Service; The five rights of medication pass included LPN #1. A review of the facility-provided scheduled list did not reflect LPN #1 was in the facility from 5/27/23 to 5/31/23. 2. A review of Resident #390's [NAME] dated 5/30/23, signed by the DON included the following: Date of Error: 5/29/23 at 9:00 PM and 5/30/23 at 6:00 AM Date of Error Discovery: 5/30/23 at 9:00 AM Medication/Treatment involved: Klonopin Type of Error: Incorrect dose Explanation/Reason medication error was made: Resident was previously receiving 0.25 mg tabs (4 to equal 1 mg) and the new bingo card was delivered with 1 (one) mg tab and the nurse subsequently gave 4 (four) without confirming the right dose. Actions Taken: Resident assessed. MD was made aware. Family was made aware. Nurse written up and educated. The [NAME] also revealed that on 5/29/23 and 5/30/23, LPN #3 administered the incorrect dose to the resident because the dosage of the tabs had changed, and the nurse failed to perform a dose check prior to administration. LPN #3 signed the acknowledgment of the incident communication on 5/31/23. Under employee comments, LPN #3 wrote, Resident was previously receiving 0.25 mg and I popped the usual 4 (four) tabs Resident always receives. Seeing that the previous nurses gave and sign the same, I assumed still the same usual dose. Forgetting that pharmacy delivered a new blister card of 1 (one) mg instead of 0.25 mg. I admit my error .Med was crushed patient took a sip and the rest was discarded. A review of the IR dated 5/30/23, under Immediate Action Taken, revealed Resident was assessed, BP was 99/50, 76 (pulse rate), 98.1 (temp), O2 saturation variable in the 80s-90s on 2 (two) L (liters) of O2 via NC. MD was made aware with no new orders. Resident is DNR/DNI on hospice. Family made aware. Resident continues to be observed and doses for 2 PM and 9 PM have been scheduled to be held for today. A review of the Order Audit Report revealed on 5/30/23 at 11:34 AM, a hold order was created by the DON, ordered by the MD; the reason was a medication error, and the resident received additional doses. On 5/30/2023 at 11:27 AM, LPN #2 documented: Medication error noted, Klonopin on evening of 5/29 and morning of 5/30. Resident assessed, VS (Vital Signs): 99/50, 76, 98.1, 16, O2 sat variable in the 80's-90's on 2 LPM (liters per minute). MD made aware with no new orders. Resident is on hospice DNR/DNI. Will continue to observe resident for any changes. UM (Unit Manager) to call family and make them aware. A review of the Order Summary Report for May 2023 indicated that the Clonazepam (Klonopin) ODT 1 (one) mg, give one tab by mouth three times a day, related to generalized anxiety with a start date of 5/16/23 was placed on a hold from 5/30/23 at 11:34 AM to 5/31/23 at 5:59 PM. On 5/31/23 at 6:06 AM, LPN #3 documented, Medication on hold for low blood pressure. A review of the vital signs revealed the resident's O2 saturation levels from baseline had changed on 5/28/23 to 6/02/23 and required administration of supplemental oxygen by way of nasal cannula (NC). The vital signs reviewed included the following: Oxygen saturation 6/02/2023 11:40 PM 95.0 % Oxygen via NC 6/02/2023 10:50 AM 95.0 % Room Air 6/01/2023 7:42 PM 97.0 % Room Air 6/01/2023 10:51 AM 96.0 % Room Air 5/31/2023 10:15 AM 96.0 % Room Air 5/31/2023 10:16 AM 94.0 % Oxygen via NC 5/30/2023 10:41 PM 95.0 % Oxygen via NC 5/30/2023 09:36 AM 96.0 % Oxygen via NC 5/29/2023 11:11 PM 95.0 % Room Air 5/29/2023 10:27 AM 93.0 % Oxygen via NC 5/28/2023 8:00 PM 93.0 % Room Air 5/28/2023 02:27 PM 92.0 % Oxygen via NC 5/27/2023 8:07 PM 98.0 % Room Air 5/27/2023 10:39 AM 95.0 % Room Air 5/27/2023 10:39 AM 95.0 % Room Air 5/26/2023 10:42 AM 95.0 % Room Air 5/26/2023 06:14 AM 97.0 % Room Air 5/24/2023 8:05 PM 98.0 % Room Air 5/24/2023 09:26 AM 97.0 % Room Air 5/23/2023 7:22 PM 98.0 % Room Air 5/23/2023 10:58 AM 95.0 % Room Air 5/23/2023 01:14 AM 95.0 % Room Air 5/22/2023 10:19 AM 95.0 % Room Air 5/21/2023 8:09 PM 98.0 % Room Air 5/21/2023 09:34 AM 96.0 % Room Air 5/20/2023 10:42 AM 94.0 % Room Air 5/19/2023 11:34 PM 96.0 % Room Air 5/19/2023 12:03 PM 96.0 % Room Air 5/18/2023 8:31 PM 98.0 % Room Air 5/18/2023 11:19 AM 95.0 % Room Air 5/18/2023 00:42 AM 96.0 % Room Air 5/17/2023 02:33 PM 95.0 % Room Air 5/16/2023 11:43 PM 95.0 % Room Air 5/16/2023 10:33 AM 95.0 % Room Air 5/16/2023 01:40 AM 96.0 % Room Air 5/15/2023 10:42 AM 95.0 % Room Air Review of the Blood Pressure 6/09/2023 02:05 PM 101/67 mmHg Sitting r/arm (right/arm) 5/09/2023 02:36 PM 105 /65 mmHg Sitting l/arm (left/arm) 5/02/2023 06:21 AM 122 /64 mmHg Lying l/arm Review of the Pulse 6/09/2023 02:05 PM 78 bpm (beats per minute) Regular 5/09/2023 02:36 PM 78 bpm Regular 5/02/2023 06:21 AM 68 bpm Regular Review of the Respirations 6/09/2023 02:05 PM 78 bpm Regular 5/09/2023 02:36 PM 78 bpm Regular 5/02/2023 06:21 AM 68 bpm Regular Further review of the vital signs from May 2023 through June 9, 2023, revealed that the resident was not monitored for blood pressure, pulse, and respirations on 5/27/23, 5/28/23, 5/29/23, 5/30/23, and 5/31/23 when the resident had adverse effects from medication errors identified which included a change in condition as evidenced in the PN, RI and [NAME]. A review of the Licensed Nurse Competency Checklist dated 4/26/23 for LPN #3 did not include a Medication Pass Observation. A review of the facility In-Service (education); The five rights of medication pass, dated 5/29/23 did not include LPN #3. On 7/26/23 at 10:38 AM, the surveyor interviewed the Consultant Pharmacist (CP). The CP confirmed that he had not provided an in-service regarding the Clonazepam. On 7/26/23 at 11:02 AM, during an interview with the surveyor, LPN #1 informed the surveyor that during the medication pass on 5/29/23, she noticed the medication card (a multi-dose card containing individually packaged medications) for Clonazepam 1 (one) mg and compared it to the eMAR and I wondered why the other nurses gave 4 (four) tablets. LPN#1 further stated that I then called hospice, the physician, the family and told my supervisor. On 7/26/23 at 11:39 AM, the surveyor interviewed the physician of the resident. The physician stated that I do not recall if that was communicated to me, with regard to the 3/24/23 recommendation of the psychiatrist for Clonazepam 0.5 mg tab three times a day and was transcribed as 1 mg three times a day. The physician further stated that the psych (psychiatrist) has prescribing privileges. On 7/26/23 at 01:28 PM, the surveyor interviewed the DON in the presence of the survey team. The DON stated, Once a medication error occurred, we fix it right away and let the MD and family know. The DON further stated, I completed the IR and a medication error report. The DON also stated that at that time Resident #390 appeared to have declined but I can't correlate that it is from the error. At that same time, the DON stated that Resident #390 was lethargic and calling out when the resident received Klonopin more than what was prescribed. She further stated that We educated some of the nurses on the 5 (five) rights of medication administration. Furthermore, the DON stated, I held the medication because of the medication administration error. On 7/27/23 at 12:52 PM, the survey team met with the Regional Director of Nursing (RDON), the License Nursing Home Administrator (LNHA), and the DON. The DON acknowledged the physician's order should be followed. At that time, the RDON stated following a physician's order was based on accepted standards of professional practice to avoid negative outcomes for the resident. At that time, the LNHA confirmed the significant medication error for Klonopin and that the resident received more than the prescribed order. On 7/28/23 at 11:40 AM, during a meeting with the survey team, the DON stated that LPN #2 was written up yesterday (7/27/23), for the medication error [transcription error] of placing an order for the Clonazepam as 1 (one) mg as opposed to the intended 0.5 mg recommended by the PNP on 3/24/23; identified after surveyor inquiry. The DON confirmed that LPN#2 did not have a medication pass observation and was scheduled for a medication pass observation on that day. A review of the provided facility policy; Medication Errors included the following. Policy Statement: In the event of a medication error, the facility will act promptly to assess for adverse consequences, notify the physician, carry out follow-up orders as directed by the physician, and address the route cause of the error. Policy Interpretation: 3. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: a. Requiring medication discontinuation or dose modification. d. Requiring treatment with prescription medication. NJAC 23.2(a); 27.1(a); 29.2(d)

Complaint # NJ00164623 Based on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure a) medication was accurately received, administered, and reconciled against the physician order prior to administration which contributed to a repeated administration of an incorrect dose to and proper disposal of Clonazepam (Klonopin; a hazardous, controlled substance/narcotic medication (med) to prevent and treat anxiety disorder), for Resident #390, b) accurate signing for a medication in the electronic medication administration record (eMAR), accurate accounting, dispensing, and administration of a controlled substance med, and med was administered according to physician orders and acceptable standards of practice, for Resident #78 and #47. This deficient practice was identified for three (3) of (3) residents (Resident #390, Resident #78, and Resident #47) reviewed for Clonazepam. 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 case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Institute for Occupational Safety and Health (NIOSH) list of Antineoplastic and Other Hazardous Drugs in Healthcare settings, 2016. Table 3 Table 3 primarily meet the NIOSH criteria for reproductive hazards. They represent a potential occupational hazard to males or females who are actively trying to conceive, women who are pregnant or may become pregnant, and women who are breast feeding, as they may be present in breast milk. Unopened, intact tablets and capsules may not pose the same degree of occupational risk as injectable drugs that usually require extensive preparation. Cutting, crushing, or otherwise manipulating tablets and capsules will increase the risk of exposure to workers. The manufacturer's safe-handling guidance (MSHG) is typically in Section 16 of the DPI. See Table 5 for safe handling recommendations . Table 3 list included but were not limited to the following: Clonazepam, Increased risk of congenital abnormalities when taken in first trimester; FDA Pregnancy Category D 1. On 7/25/23 at 10:42 AM, the surveyor reviewed Resident #390's medical record. The Admission Record (AR; or face sheet; an admission summary) reflected the resident was admitted with diagnoses which included Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), unspecified dementia (loss of cognitive functioning), bipolar disorder (mental illness that causes unusual shifts in mood from extreme high to extreme low), dysphagia (difficulty swallowing), peripheral vascular disease (circulation disorder), major depressive disorder (persistent feeling of sadness and loss of interest) and generalized anxiety disorder. The most recent Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, dated 5/04/23, reflected that the resident had a brief interview for mental status (BIMS) score of 6 out of 15, which indicated the resident had a severely impaired cognition. Further review of the MDS section E Behavior indicated the resident was not delusional and section N Medications reflected the resident received antipsychotic and antianxiety medications. The resident's personalized care plan revised on 8/03/22, under the section Intervention/ Tasks, included review medications (meds) and record possible causes of cognitive deficit: new meds or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. A review of the Order Summary Report (OSR) dated 5/01/23 to 5/31/23, included an order for Clonazepam with a start date of 5/16/23, and reflected the following: Clonazepam ODT 1 (one) mg (milligram), Controlled Drug, give 1 tablet by mouth three times a day related to generalized anxiety disorder. A review of the Controlled Drug Record (CDR; a narcotic log/form used to inventory and document each dose of med administered or disposed) with a pharmacy provider label for Clonazepam ODT 0.25 mg, give 4 (four) tablets by mouth three times a day was signed received on 5/18/23, for 90 doses. Further review of the CDR revealed that the med was signed removed from inventory for administration by the nurses from 5/19/23 to 5/27/23 at 2:00 PM. A review of the electronic Medical Record (eMR) did not reflect a physician's order to correspond with the CDR for Clonazepam ODT 0.25 mg that was signed received on 5/18/23, signed removed for administration for 90 doses. A review of the Medication Error Incident Report ([NAME]) dated 5/29/23, revealed under Explanation/ Reason medication error was made reflected Resident was previously receiving 0.25 mg tabs [tablets] (4 to equal 1 mg) and the new bingo card was delivered with 1 (one) mg tabs and nurse subsequently gave 4 (four) without confirming the right dose. A review of the [NAME] dated 5/30/23, revealed under Explanation/ Reason med error was made reflected Resident was previously receiving 0.25 mg tabs [tablets] (4 to equal 1 mg) and the new bingo card was delivered with 1 (one) mg tabs and nurse subsequently gave 4 (four) without confirming the right dose. Further review of the eMAR for Resident #390 reflected the following: -On 5/04/23 at 2:00 PM, the eMAR was signed absent from home without meds. -On 5/11/23 at 2:00 PM, the eMAR was signed absent from home without meds. -On 5/28/23 at 6:00 AM, the eMAR was signed refused. A review of the CDR for Resident #390 revealed the following: On 5/04/23 at 02:00 PM, one tablet of Clonazepam 1 (one) mg was removed from inventory for administration. No documentation of disposal was annotated on the CDR. On 5/11/23 at 02:00 PM, one tablet of Clonazepam 1 (one) mg was removed from inventory for administration. No documentation of disposal was annotated on the CDR. -On 5/28/23 at 6:00 AM, four tablets of Clonazepam 1 (one) mg were removed from inventory for administration. No documentation of disposal was annotated on the CDR. On 7/26/23 at 9:48 AM, during a telephonic interview with the surveyor, the provider pharmacist stated the physician or nurse enters the order into the eMR, electronically signs off and is transcribed into their system. On 7/27/23 at 10:14 AM, the survey team met with the Regional Director of Nursing (RDON), License Nursing Home Administrator (LNHA), and the Director of Nursing (DON) and were made aware of the above findings. At that time, the LNHA stated that she spoke with the provider pharmacy when the medication error occurred. The LNHA was concerned why the physician's order (PO) on the eMR did not match the med received. She was informed by the pharmacy that they are unable to see what is on the eMR. At that time, the LNHA informed the surveyor that in the event of a discrepancy between a PO and a med received, the nurses would call the pharmacy to rectify the discrepancy and get the correct order for the resident. On 7/27/23 at 12:52 PM, during a meeting with the survey team, the RDON, and LNHA, the DON acknowledged the PO should be followed. At that time, the RDON stated following a PO was based on accepted standard of professional practice to avoid negative outcomes for the resident. At that time, the LNHA informed the surveyor that in the event of a discrepancy between a PO and a med received the nurses would call the pharmacy to rectify the discrepancy and get the correct order for the resident. At that time, the DON acknowledged the med received from the pharmacy should have been reconciled for accuracy against the PO. On that same date and time, during a meeting with the survey team, RDON, and LNHA, the DON informed the surveyor that she was aware the med was refused on 5/28/23 at 6:00 AM. The DON stated it did not cross her mind to in-service (provide education) regarding proper disposal of Clonazepam. 48273 2. On 7/20/23 at 10:34 AM, the surveyor observed Resident #78 seated up on the bed awake, alert, and responded appropriately to the surveyor. The surveyor also observed the Certified Nursing Assistant (CNA) assisted the resident with breakfast. The surveyor reviewed Resident #78's medical record. The AR reflected that the resident was admitted to the facility which included diagnoses that included but were not limited to type 2 diabetes mellitus with hyperglycemia (abnormal blood glucose level), hypothyroidism (deficiency of thyroid hormones can disrupt such things as heart rate, body temperature, and all aspects of metabolism), hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), Alzheimer's Disease, essential hypertension (elevated blood pressure), unspecified dementia, and anxiety disorder. A review of Resident #78's PO presented an order initiated on 5/05/23 for Alendronate Sodium (medication use to treat osteoporosis) Oral Tablet 70 mg, 1 (one) tablet by mouth weekly for osteoporosis (A condition in which bones become weak and brittle). The medication order was changed on 7/12/23 to Alendronate Sodium Oral Tablet 70 mg, 1 (one) tablet by mouth one time a day every Sunday for osteoporosis - give with 8 (eight) ounces of plain water, at least half hour before all other food, beverage, or med; do not lie down for half hour. The surveyor reviewed the eMAR for Resident #78 for the med administration of Alendronate Sodium Oral Tablet 70 mg, 1 (one) tablet by mouth weekly for osteoporosis, which revealed the following: For the month of May 2023, the nurses signed 23 out of 27 days that the med was administered. For the month of June 2023, the nurses signed 29 out of 30 days that the med was administered. For the month of July 2023, the nurses signed 11 out of 12 days that the med was administered. On 7/25/23 at 01:05 PM, the surveyor interviewed the DON regarding the above concerns for the Alendronate Sodium medication. The DON stated when the order was entered for Alendronate Sodium 70 mg give 1 (one) tablet by mouth weekly on 5/05/23, it was selected for the nurses to document daily instead of weekly. The CP identified the error in 7/08/23, and the DON initiated an investigation for the med documentation error. The DON further stated that the investigation concluded that the nurses were signing the eMAR daily and not administering the med, as the med was not available to be given every day. On 7/26/23 at 11:59 AM, the surveyor interviewed LPN #2, who was assigned previously to Resident #78 and signed for the Alendronate Sodium medication in the eMAR. LPN #2 stated the Alendronate Sodium was to be given weekly and she observed the med was being signed daily. She stated she did not administer the med and documented a progress note dated 5/13/23 and 5/14/23 that she did not give the med because it was already given for the week. LPN #2 acknowledged that it was expected for the nurses to report a concern about a med order and that it should have been reported for follow up to the supervisor. 3. On 7/26/23 at 01:45 PM, the surveyor reviewed the CDR form for Resident #78 on the Magnolia unit med cart. The surveyor reviewed Resident #78's CDR form for Clonazepam 0.5 mg 1/2 (half) tablet (0.25 mg) by mouth every 12 hours as needed for Anxiety for 14 days, which revealed two entries on 7/16/23 at 11:20 AM. Indicating Resident #78 received Clonazepam 0.5 mg. The surveyor reviewed the PO for Resident #78 which revealed an order initiated on 6/09/23 for Clonazepam give 0.5 tablet by mouth every 12 hours as needed for anxiety for 30 days - 0.5 tablet = 0.25 mg, which was discontinued on 7/09/23. Further review of the PO revealed an order initiated on 7/14/23 for Clonazepam 0.5 mg 1 (one) tablet every 8 (eight) hours as needed for anxiety/agitation for 30 days. Further review of resident's CDR revealed the following: On 7/20, 7/21, 7/22, and 7/25 entries documented a single Clonazepam 0.5 mg 1/2 (half) tablet (0.25 mg) was signed out for each of these days. The surveyor reviewed July eMAR, which indicated on 7/20, 7/21,7/22, and 7/25 med Clonazepam 0.5 mg 1 (one) tablet was administered. On 7/26/23 at 02:00 PM, the surveyor interviewed LPN #3, who was the assigned nurse for Resident #78 and confirmed the count of the Clonazepam in the med cart. The surveyor reviewed with LPN #3 the CDR for the Clonazepam. LPN#3 stated that the nurses who were administering the med should have reviewed the directions of the med prior to administering the med. She further stated that when the new bingo card with the correct dose was received that the discontinued med should have been remove from the med cart. On 7/26/23 at 02:10 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) about the process for when a med order was changed. UM/LPN stated when a doctor changed the order that they will fax the new order to the pharmacy. When a new order is received from the pharmacy, the discontinued order will be remove from active med stock. The med nurse will give her the unit manager the discontinued med and that med will be destroyed in the presence of two nurses. On 7/27/23 at 12:52 PM, the surveyor informed the LNHA, DON, and RDON about the above concerns with the Alendronate Sodium med and the Clonazepam med for Resident #78. The DON acknowledged there was a med error, in which an investigation was completed. 46049 4. The surveyor reviewed the hybrid (electronic and paper) medical records for Resident #47, which revealed the following: The resident's AR listed diagnoses that included but were not limited to, unspecified dementia, major depressive disorder, and anxiety disorder. A review of the July 2023 OSR and the July 2023 eMAR indicated that Resident #47 had a PO, dated 6/30/23 for Clonazepam 0.5 mg, give 1 (one) tablet by mouth two times a day for anxiety, which was discontinued on 7/11/23. A PO, dated 7/11/23, was started for Clonazepam 1 (one) mg, give 1 tablet by mouth three times a day for anxiety. On 7/26/23 at 02:09 PM, the surveyor interviewed the UM/LPN about the CDR. The UM/LPN stated upon completion of a CDR, it would be removed from the binder in the med cart, and that it would be given to the DON. The surveyor asked the UM/LPN what the expectations were for when a nurse wasted a controlled med. UM/LPN stated two nurses were to waste (destroy) a controlled med, to witness and co-sign the disposal of the med. The surveyor requested from the UM/LPN the Clonazepam drug records for Resident #47. On 7/27/23 at 10:01 AM, the surveyor interviewed the DON about CDR keeping. The DON stated she kept all original CDR forms for record keeping. The surveyor requested from the DON the Clonazepam 0.5 mg, CDR forms for Resident #47. On 7/28/23 at 10:10 AM, the DON provided the surveyor the Clonazepam 0.5 mg July 2023 CDR forms for Resident #47. A review of the July 2023 CDR forms for Clonazepam 0.5 mg revealed the following: For the entry dated and timed, 7/13 9 PM, LPN #4 signed out for Clonazepam 0.5 mg, 1 (one) tablet. The physician's order was for Clonazepam 1 (one) mg to be administered and LPN #2 signed on the eMAR that Clonazepam 1 (one) mg was administered on 7/13/23 at 9 PM. For the entries dated and timed, 7/14 9 AM, 2 PM and 9 PM, LPN #1 signed out Clonazepam 0.5 mg 1 (one) tablet at each of those times. The physician's order was for Clonazepam 1 (one) mg to be administered. LPN #1 signed on the eMAR that Clonazepam 1 (one) mg was administered on 7/14/23 at 9 AM, 2 PM, and 9 PM. For the entries dated and timed, 7/15 9 AM and 2 PM, LPN #1 signed out Clonazepam 0.5 mg, 1 (one) tablet. The physician's order was for Clonazepam 1 (one) mg to be administered. LPN #1 signed on the eMAR that Clonazepam 1 (one) mg was administered on 7/15/23 at 9 am and PM. For 7/17/23, there were no entries on the controlled drug records documenting Clonazepam being signed out for the 2 PM and 9 PM dose. LPN/UM signed on the eMAR that Clonazepam 1 (one) mg was administered on 7/17/23 at 2 PM and Registered Nurse (RN) #1 signed that Clonazepam 1 (one) mg was administered on 7/17/23 at 9 PM. For the entry dated and timed 7/18 9 AM, LPN #1 signed out two Clonazepam 0.5 tablets. LPN #1 did not sign eMAR for 7/18/23 at 9 AM, the eMAR was signed by LPN #5. LPN #1 worked on 7/19/23. There were no other entries on the CDR forms for the 7/18/23 9 AM, 2 PM, and 9 PM dose to document Clonazepam being signed out for administration to the resident. LPN #5 signed the eMAR on 7/18/23 for 9 AM and 2 PM that Clonazepam 1 (one) mg was administered to the resident. LPN #6 signed the eMAR for 7/18/23 at 9 PM that the med was administered. For the entries dated and timed 7/19 2 PM, LPN #1 signed out two Clonazepam 0.5 mg tablets. On the eMAR, LPN #1 signed, the chart code 5 for the Clonazepam 1 (one) mg to be administered on 7/19/23 at 2 PM. The chart code 5 indicated Hold/See Progress Notes. A review of the Administration note, LPN #1 documented awaiting order from pharmacy. There was no documentation to account if the two Clonazepam 0.5 mg tablets signed out by LPN #1 were wasted or administered to the resident. A review of the July 2023 CDR for Clonazepam 1 (one) mg which was currently in use for Resident #47 revealed the following: For the entry dated and timed 7/22 9 PM, LPN #6 signed their name and wrote wasted to indicate the Clonazepam 1 (one) mg tablet signed out was destroyed. There was no co-signature by another nurse on the entry to document that the wasting of the med was witnessed. On 7/28/23 at 10:25 AM, the surveyor informed the DON and LNHA of the above concerns. The DON stated it was expected for the nurses to follow the PO and if the dose of a med was not available the physician should be called, and the order clarified. The DON further stated it was expected for the nurses to have a second nurse to witness and co-sign on the controlled drug record when a controlled med was wasted (destroyed). The LNHA acknowledged the nurses were expected to follow the PO and administer med accurately. The DON and LNHA stated they would follow up and provide further information. On 7/28/23 at 11:59 AM, the survey team met with the LNHA, DON, and Regional Chief Nursing Officer. The DON confirmed the nurses could only provide the resident with Clonazepam from the resident's med supply in the med cart, that would require the nurses to sign and document on the CDR form. The DON stated there was no alternate access for the Clonazepam med and that there was no back up controlled med stock in the facility. The LNHA provided the surveyor with the controlled substances policy. A review of the facility provided policy; Accepting Delivery of Medications reviewed/revised 01/2023, included the following: Policy Statement 2. Any errors noted in receiving meds shall be brought to the attention of the Pharmacist and Director of Nursing Services. Policy Interpretation and Implementation 2. Before signing to accept the delivery, the Nurse must reconcile the meds in the package with the delivery ticket/order receipt. 3. If an error is identified when receiving meds from the pharmacy, the Nurse verifying the order shall: b. Return incorrect meds (e.g. wrong strength, form etc.) to the dispensing pharmacy and reorder the correct med. A review of the facility provided policy; Discarding and Destroying Medications reviewed/revised 1/2023 included the following: Policy Interpretation and Implementation 8. Any controlled substance that is considered hazardous waste will be managed in accordance with federal, state and local hazardous waste regulations as well as the Controlled Substance Act and DEA regulations. 10. The med disposition record will contain the following information: a. The resident's name b. Date med disposed e. quantity disposed f. method of disposition h. signature of witnesses A review of the facility provided policy; Controlled Substances dated 11/2022 included the following: Policy Interpretation and Implementation 9. The Director of Nursing services shall investigate any discrepancies in narcotic reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. A review of the facility's policy titled, Controlled substances, dated 12/2018, under policy statement read: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. The policy did not further address documentation by nurses at the time of medication being signed out and administered. The policy also did not address the procedure by nurses for destroying and documenting the wasting of a controlled medication. A review of the facility's policy titled Administering Medications, dated 11/2022, under Policy Statement read, Medications shall be administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation, it read: 3. Medications must be administered in accordance with the orders .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . On 7/28/23 at 01:11 PM, the facility had no further information to provide. NAACP 8:39-11.2 (b), 29.2 (d), 29.4(G)(I)(Mk), 29.7(ac)

Complaint NJ 453 Based on observation, interview, and record review, it was determined that the facility failed to protect residents from physical abuse and failed to report witnessed abuse immediately to Administration. This deficient practice was identified for two residents, Resident #1 and Resident #19. The abuse was perpetrated by one Certified Nursing Assistant (CNA) and was witnessed by two other CNAs. Both incidents, which occurred on the same day, were not reported to the facility by the witnesses until five days after the abuse incidents took place. All three CNAs continued to work with the residents during this period. The Survey team identified this Immediate Jeopardy situation on 4/26/16 at 10:30 a.m. An acceptable Plan of Correction (POC) was accepted at 5:30 p.m. on 4/26/16 and the Immediate Jeopardy was lifted. The survey team verified the plan of correction on 4/26/16. This deficient practice was evidenced by the following: 1. The surveyor reviewed the closed record for Resident #19 on 4/26/16 at 9:30 a.m. The Resident was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS), a functional assessment tool, was completed on 7/20/15 by the Interdisciplinary Team (IDC). The IDC Team assessed that the resident required total assistance of one person for toileting and limited assistance of one person for ambulation. The resident had a care plan for cognitive impairment and was described as disoriented and non-verbal. On 4/25/16 and 4/26/16 the surveyor reviewed the Facility's Investigation Report regarding the incident that occurred on 8/5/15. The facility obtained written statements from the CNA who witnessed the event and the CNA who abused the resident on 8/11/15. The CNA who witnessed the event stated she did not report the abuse immediately because she was afraid. The CNA who witnessed the event stated that Resident #19 would not get up from the toilet so she requested assistance from the abusive CNA. The abusive CNA began to pull the resident's hair and pull the nipple on the resident's breast to get the resident to stand up. The facility noted no injuries upon assessment of the resident on 8/10/15 when the abuse was reported. 2. The surveyor observed Resident #1 on 4/20/16 at 1:30 p.m. in a low bed. The right side of the bed was to the wall, the left siderail was raised and padded, and there were two regular mattresses next to the bed on the left. The resident's eyes were closed and the resident did not respond to a verbal greeting. The surveyor reviewed the resident's medical record on 4/21/16 at 9:10 a.m. The resident was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. An Annual MDS was completed on 5/15/15 by the IDC Team. The IDC Team assessed that the resident was confused, that s/he required extensive assistance of one person for Activities of Daily Living, including Hygiene and Toileting and that the resident was non-ambulatory. The resident was also noted by the team to be highly visually impaired. Behaviors identified included screaming, resisting care, verbal behaviors, hallucinations and delusions. The IDC Team developed care plans to provide care specific for this resident. On 4/25/16 and 4/26/16 the surveyor reviewed the Facility's Investigation Report regarding the incident of 8/5/15. The facility obtained written statements from the CNA who witnessed and reported the event and the CNA who abused the resident on 8/11/15. The facility also obtained a statement dated 8/14/15 from the CNA who was assisting the abusive CNA with the resident. The CNA who reported the event stated that on 8/5/10 while walking by the shower room, she saw the abusive CNA giving Resident #1 a shower. The resident was yelling and the abusive CNA began hitting the resident and grabbing the resident's face. The CNA who was assisting the abusive CNA in the shower stated that the resident screamed because of the cold water but that the abusive CNA slapped the resident's face and held the resident's mouth shut. The facility noted no injuries upon assessment of the resident on 8/10/15 when the abuse was reported. These incidents were not brought forward to Administration until 8/10/15, five days after the incidents. The abuser continued to work with residents. The witnesses, aware of this abuse, also continued to work and failed to come forward for five days until one of the CNAs came forward to Administration. Only one CNA came forward to report both incidents. The other CNA remained silent. On 4/26/16 at 5:30 p.m. the Administrator completed the Plan of Correction (POC). The survey team reviewed the POC which included the following elements: i. Both Resident #1 and #19 were assessed immediately on 8/10/15 to rule out any injuries and continued to be monitored. Resident #19 was discharged . The CNA who perpetrated the abuse was immediately suspended and then terminated. The 2 witnesses were immediately in-serviced and disciplined. ii. All residents on accused CNA's assignment were assessed at the time of discovery. iii. In-services were conducted by 8/21/15 for all staff following identification of abuse on 8/10/15. Inservices were repeated again starting on 4/26/16 on all shifts. Unit managers or Charge Nurse designees will monitor care provided by CNAs on all shifts by doing spot checks. iv. Resident and Family Satisfaction Surveys will be conducted quarterly. v. DON or designee will audit results of CNA monitoring and Satisfaction Surveys. DON will report the results of these audits to the QA Committee quarterly. NJAC 8:39-9.4(e)3(i)