Every finding on record at Foothill Acres Rehabilitation & Nursing Center

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food-borne illness. This deficient practice was evidenced by the following: On 5/15/26 at 10:07 AM, the surveyor entered the facility's kitchen and conducted an interview with the Food Service Director (FSD) who stated the food in the refrigerators and freezers should be sealed in an air-tight wrap and labeled with a use by date. The FSD further stated the dietary staff were responsible for maintaining the nursing unit pantry inventory to ensure there were no expired items. At 10:29 AM, the surveyor, accompanied by the FSD and the Regional Food Service Director (RFSD), observed the following in the kitchen: In the Walk-In Freezer:1. There was a two-inch steam pan of chicken parmesan that was sealed without a prepared or use-by date. The RFSD discarded the chicken parmesan. 2. There was a 10.5 ounce (oz) bag of vegan chicken nuggets that was open and not resealed, leaving the contents of the bag exposed. The RFSD discarded the bag of vegan chicken nuggets. On 5/21/26 at 11:02 AM, the surveyor, accompanied by Licensed Practical Nurse/Unit Manager (LPN/UM) #1, observed the following in the 200 Unit pantry:1. In the freezer, there was a styrofoam cup that was not labeled. The LPN/UM removed it from the freezer to look inside the cup and an Activities Aide (AA) took the cup from her hand and began drinking from it. The AA acknowledged that the cup belonged to him and the LPN/UM stated he should not store his food/drinks in the resident refrigerator.2. In the refrigerator, there was a 15.2 oz bottle of juice with an expiration date of 3/20/26. The LPN/UM verified the juice was expired and discarded it. During an interview at that time, the LPN/UM stated the dietary staff were responsible for checking the pantry refrigerators for expired items and that the facility staff were not supposed to store their food/drinks in the resident refrigerators. On 5/21/26 at 11:13 AM, the surveyor, accompanied by Registered Nurse/Unit Manager (RN/UM) #1, observed the following in the 400 Unit pantry:1. In the freezer, there was a previously opened container of ice cream that was labeled with a resident's name and room number, but did not include the date the ice cream was placed in the freezer or a use-by date. The RN/UM stated she would find out when the ice cream was placed into the freezer.2. On the ice machine, there was a build up of a white substance along the ice dispenser. The RN/UM stated she would get someone to clean the ice machine. During an interview at that time, the RN/UM stated the dietary staff were responsible for checking the pantry refrigerators for expired items and that the ice machine was cleaned daily and should not have a build up of a white substance. The facility provided a copy of the 400 Unit ice machine maintenance log that revealed the ice machine was last cleaned 3/24/26. On 5/21/26 at 12:27 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that all food in the kitchen should be labeled with an expiration date, all food should be sealed properly, the food in the pantries should be stored under the facility's guidelines, and the ice machine should be clean. A review of the facility's Dating and Labeling policy, undated, included:Every food item that is prepared, opened, or removed from its original packaging must be labeled with:. the date the product was prepared or opened.All foods must be stored in food grade containers and tightly wrapped with a date and label. Do not leave open items in any storage areas (cold or dry). A review of the facility's Food/Beverages from Outside policy, revised 1/12/26, included:All food and beverage items that are brought into the facility must be labeled with the resident's name and date of delivery before being placed in refrigerators.All food items must be dated with receiving date and/or manufacturer's use-by date.All packaged/sealed food items will be discarded upon expiration date. A review of the facility's Unit Pantries policy, revised October 2025, included:Opened food items must be. labeled with opening date. Staff shall routinely inspect pantry items for expiration dates.Expired, spoiled, or contaminated food shall be discarded immediately.Resident-labeled food items shall be clearly identified and dated.Expired resident food items shall be discarded according to facility policy.Dietary department monitors food storage and sanitation compliance. A review of the facility's Ice Machine policy, revised January 2023, included:Ice machines shall be cleaned and disinfected:. immediately when visibly soiled.Cleaning shall include: interior surfaces, exterior surfaces,. gaskets and dispensers.The Infection Preventionist, Dietary Manager, or Maintenance Department shall inspect ice machines routinely for: mold or slime buildup. NJAC 8:39-17.2(g)

Based on interviews, record reviews, and a review of facility documentation, it was determined that the facility failed to consistently implement an Antibiotic Stewardship Program (ASP) (a program designed to improve clinical outcomes and reduce harm by promoting appropriate antibiotic use and monitoring prescribing practices). The facility did not utilize standardized infection surveillance criteria to determine whether antibiotic use was appropriate. This deficiency was identified in 3 of 6 residents reviewed for antibiotic use (Resident #61, #74, and #154) and was evidenced by the following: 1.) A review of the Infection Control Case List (ICCL) in the electronic medical record (EMR) for 5/2026 revealed Resident #61 had a right toe ulcer (RTU) (an open sore or wound on the toe resulting from skin breakdown), with an onset date of 5/18/2026. Further review of the ICCL indicated the resident was started on an antibiotic for the RTU on 5/18/2026. There was no evidence that standardized infection surveillance criteria were used to determine the appropriateness of the antibiotic prescribed. 2.) A review of the ICCL in the EMR for 5/2026 revealed Resident #74 had bronchitis (inflammation of the airways in the lungs), with an onset date of 5/8/2026. Further review of the ICCL indicated the resident was started on an antibiotic for bronchitis on 5/8/2026. There was no evidence that standardized infection surveillance criteria were used to determine the appropriateness of the antibiotic prescribed. 3.) A review of the ICCL in the EMR for 5/2026 revealed Resident #154 had a tooth infection, with an onset date of 5/19/2026. Further review of the ICCL indicated the resident was started on an antibiotic for the tooth infection on 5/19/2026. There was no evidence that standardized infection surveillance criteria were used to determine the appropriateness of the antibiotic prescribed. On 5/19/2026 at 11:40 AM, the surveyor interviewed the Infection Preventionist (IP), who reported she has worked at the facility for seven years and had served in the IP role since October 2024. She indicated residents must meet criteria prior to initiation of antibiotics and that the facility utilized both the Loeb Criteria and McGeer Criteria for infection identification and antibiotic stewardship. The IP further stated there was no formal checklist in place to ensure clinicians prescribed antibiotics in accordance with the McGeer criteria. She stated nursing staff notified her when a resident was started on antibiotics, and she reviewed the criteria; however, this review was not documented. On 5/20/2026 at 10:04 AM, the surveyor interviewed the Director of Nursing (DON), who reported she had served as the DON for five years. The DON indicated the facility utilized the McGeer Criteria, not the Loeb Criteria, for antibiotic stewardship and infection surveillance. The DON stated nursing staff were expected to be knowledgeable regarding the criteria utilized by the facility for antibiotic stewardship. She further confirmed the IP should complete and document the McGeer checklist rather than solely reviewing the criteria. On 5/20/2026 at 11:14 AM, the surveyor interviewed the Certified Pharmacist Consultant (CPC) via telephone, who reported the facility utilized the McGeer Criteria for antibiotic stewardship, and that the criteria were reviewed monthly as part of her consultation process which included reviewing progress notes, laboratory results, and other clinical documentation to determine whether McGeer Criteria were met. A review of the facility's Antibiotic Stewardship Program policy, dated 1/12/2026, included The Antibiotic Stewardship Program (ASP) shall monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing which may include but not limited to the following activities in a manner needed to assure patient safety and met the new Centers for Medicare and Medicaid services requirement for stewardship. NJAC 8:39-19.4(d)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to meet the professional standards of practice by not appropriately assessing and documenting PRN (as needed) pain medications. This deficient practice was identified for 1 of 5 residents (Resident #41) reviewed for unnecessary medications and was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 5/15/2026 at 9:54 AM, during initial tour, the surveyor observed Resident #41 lying in bed with their eyes closed. Resident #41 did not acknowledge or speak with the surveyor. On 5/18/2026 at 10:06 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #41. A review of the admission Record, (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; pressure ulcer of the sacral region stage 4, Parkinson's Disease, dementia, dysphagia, and adult failure to thrive. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/25/2026, included the resident had a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident was unable to complete the interview due to severe cognitive impairment. Further review of the MDS revealed the resident was prescribed medications that included antipsychotics, antidepressants, opioids, and anticonvulsants. A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 6/23/2024, for pain. Interventions included: for pain assessments to administer pain medications per physician orders. A review of the Physician Order Summary (POS), dated as of 5/21/2026, included the following physician order (PO): Tramadol HCL Oral Tablet 50 MG (milligrams); Give 1 tablet by mouth every 6 hours as needed for pain score (4-10) moderate and severe pain. A review of the December 2025 Medication Administration Record (MAR) revealed the resident was administered Tramadol HCI oral tablet 50 MG for a documented pain scale of 0 and 1 on the following days:12/3, 12/11, 12/18, and 12/28. A review of the January 2026 MAR revealed the resident was administered Tramadol HCI oral tablet 50 MG for a documented pain scale of 0, 2, and 3 on the following days: 1/1, 1/2, 1/6, 1/22, and 1/28. A review of the February 2026 MAR revealed the resident was administered Tramadol HCI oral tablet 50 MG for a documented pain scale of 0 and 1 on the following days: 2/5, 2/8, 2/12, 2/13, 2/22, 2/25, and 2/26. A review of the April 2026 MAR revealed the resident was administered Tramadol HCI oral tablet 50 MG for a documented pain scale of 0 and 2 on the following days: 4/1, 4/2, 4/9, 4/16, 4/18, and 4/30. A review of May 2026 MAR revealed the resident was administered Tramadol HCI oral table 50 MG for a documented pain scale of 0 on the following days: 5/2, 5/6, 5/7, and 5/16. On 5/19/2026 at 12:07 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) #2 who was aware of the medication errors. RN/UM #2 stated that there was one nurse that was chronically non-compliant with following the physician orders of pain level parameters. RN/UM #2 indicated that it has been addressed with the nurse on multiple occasions. A review of the facility's Pain Management policy with a review date of 1/25/2025, included, The nurse assesses the resident for signs and symptoms of pain using either the pain assessment form for the cognitively impaired or the pain assessment record . NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control practices and professional standards during a pressure ulcer treatment for 1 of 3 residents (Resident #40) reviewed for pressure ulcers. This deficient practice was evidenced by the following:On 5/20/26 at 10:34 AM, the surveyor observed Registered Nurse (RN) #1 perform a wound care treatment on Resident #40. The RN performed hand hygiene using an alcohol-based hand rub (ABHR) and then donned gloves. She wiped down the overbed table with a disinfectant wipe, removed her gloves, used ABHR, and gathered her treatment supplies onto the overbed table, which included a multi-use bottle of quarter-strength Dakin's solution (wound cleansing solution). The RN then donned gloves and a gown and entered the resident's room where two staff had already positioned the resident for the wound treatment. The RN removed the old, soiled wound dressing and disposed of it in a trash bag. With the same gloves, she then picked up a normal saline (cleansing solution) soaked gauze from the overbed table and cleaned the wound bed, picked up dry gauze to pat dry the wound bed, and measured the wound with a paper ruler, before removing her gloves and using ABHR. Afterwards, she packed the wound with Dakin's soaked gauze and covered the wound with an undated/unlabeled foam dressing. After the dressing was applied to the resident's wound, the RN then took a marker and wrote the date, time, and her initials on the middle of the foam dressing. When the treatment was completed, the RN disposed of her gloves, gown, and single use treatment supplies. She brought the overbed table to the doorway where the treatment cart was and then washed her hands. Afterwards, she donned gloves and used a disinfecting wipe to wipe down the overbed table including the multi-use bottle of Dakin's solution, but did not designate the Dakin's as resident-specific for Resident #40 before returning it to the treatment cart. At 10:57 AM, the surveyor interviewed RN #1 who acknowledged that she should have removed her gloves and performed hand hygiene after discarding the soiled wound dressing for infection control purposes. The RN also stated she should have labeled the foam dressing before applying it to the resident because it could have caused discomfort. The RN also verified that multi-use bottles, such as the Dakin's solution, should stay in the resident's room for infection control purposes. The surveyor reviewed the medical record for Resident #40. According to the admission Record, an admission summary, the resident had diagnoses which included, but were not limited to, multiple sclerosis. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/24/26, included the resident had a Brief Interview for Mental Status score of 14 out of 15, which indicated the resident's cognition was intact. The MDS further included that the resident had a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer that was present on admission. A review of the individualized comprehensive care plan (ICCP), revised 3/25/25, included a focus area that the resident had actual skin breakdown of a Stage 4 pressure ulcer on the sacrum. Interventions included: Administer treatment per physician orders. A review of the Order Summary Report, as of 5/20/26, included the following physician's order (PO):A PO, dated 11/24/25, to pack sacrum with Dakin's moist gauze and cover with foam every day and evening shift. On 5/20/26 at 12:06 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) #1 who stated that during a wound care treatment, the nurse should remove their gloves and perform hand hygiene after removing the old, soiled dressing to prevent anything infectious from entering the wound. The RN/UM further stated that wound dressings should be dated and initialed prior to applying the dressing to the wound to prevent pain. The RN/UM explained that if the wound dressing was already applied, the nurse should label a piece of tape to apply to the dressing. On 5/20/26 at 12:14 PM, the surveyor interviewed the Director of Nursing (DON) who stated that during a wound care treatment, the nurse should be changing their gloves and performing hand hygiene after removing the soiled dressing to prevent any type of cross contamination. The DON further explained that the nurse should not label the wound dressing after it was already applied to the resident because it could cause pain when pressure was applied to the wound. The DON also stated that multi-use bottles should not be brought into the resident's room, and if they were, the nurse would have to bag the bottle and designate it for the resident. The DON stated that multi-use items should be prepared prior to entering the resident's room and stored in the treatment cart. A review of the facility's Dressing Change skill evaluation form used to evaluate RN #1 on 5/20/26, included the following:Under the section titled Remove soiled dressing: c. Loosen the soiled dressing by holding the resident's skin and pulling the tape or dressing towards the wound to protect new formed tissue and remove.d.1. Place the soiled dressing in the moisture proof bag without touching the sides of the bag.f. Remove gloves and discard in prepared bag. Perform hand hygiene according to local requirements. Under the section titled Prepare supplies using clean technique:a.2.1. If a multi-use bottle is used; lip the liquid by pouring out a small of the liquid prior to dispensing. c. Prepare several lengths of tape in advance to secure the dressing.c.3. Include date, time, and nurse initials on one of the lengths of tape. A review of the facility's Wound Care policy, revised 5/7/19, did not include the steps for a wound care treatment. NJAC 8:39-27.1(a)

Based on interviews and review of pertinent facility documents, it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA) received a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI).This deficient practice was identified for 5 of 5 residents (Resident #33, #111, #122, #163 and #164) reviewed for PNA and was evidenced by: On 5/15/26 at 11:25 AM, the Director of Nursing (DON) provided the PNA balances as of 5/15/26. A review of the facility's Patient Fund Balances through 5/15/26 revealed 5 residents had balances that ranged from $1,846.70 to $2,385.22. On 5/19/2026 at 9:20 AM, the surveyor interviewed the Business Office Manager (BOM) who stated that statements were handed out each quarter but at any time the residents could request it. The BOM stated that some people did not spend their money and that either the Activities staff or herself contacted the resident or their representative to figure out how they could spend down the money. She then explained that the resident's PNA should be under $2,000.00, but was sure some residents were still over that amount. When asked if she provided a written notification or had documentation, the BOM stated there was no documentation but moving forward she would provide documentation as there probably was a letter she could use. She further stated that it was important for the resident's PNA to be under $2,000.00, so they did not get kicked off Medicaid. The BOM confirmed that when the resident reached $1,800.00, they should be notified. On 5/21/2026 at 12:36 PM, the Licensed Nursing Home Administrator (LNHA) stated in the presence of the DON, the Assistant DON (ADON), the Assistant LNHA and the survey team that his expectation would be for a letter to be sent out. He stated that it was important for the resident or their representative to be notified as they could lose their Medicaid. On 5/22/2026 at 9:37 AM, the DON stated in the presence of the ADON and the survey team that after surveyor inquiry the facility spoke with all the above-mentioned residents, and they brought their PNA down except Resident #122. She stated the resident refused but that the sister made purchases but did not provide all the receipts. So, they sent another letter as Resident #122 was still above $1,800.00. A review of the facility's Resident PNA policy dated 5/21/26, included, 3. This facility will notify each resident that receives Medicaid benefits: a.) when the amount in the resident's account reaches $200.00 less than the SSI resource limit for one person. b.) If the amount in the resident's account, reaches the SSI resource limit, the resident may lose eligibility for Medicaid or SSI. NJAC 8:39-9.5

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promotes his/her quality of life. This deficient practice was identified for one 1 of 32 residents (Resident #81) reviewed for resident rights. This deficient practice was evidenced by the following:On 5/15/26 at 12:08 PM, during the initial tour, the surveyor overheard a male voice speaking in a loud, firm tone to Resident #81, stating, Are we on the same page? Do you understand what I'm saying? To which the resident replied, Yes, I understand, I'm not stupid, and the male voice responded, Well, some people would disagree with that. When the surveyor approached the room, the man left the room and was wearing a sweatshirt with the facility's name on it. At that time, Resident #81 was sitting up in bed, tearful, and told the surveyor that the man in the room was a Physical Therapist (PT) and then reiterated the part of the conversation that the surveyor overheard. The resident stated he/she was upset that he/she would not physically be able to go home on pass, but that the PT was always mean to him/her. The surveyor reviewed the medical record for Resident #81. According to the admission Record, an admission summary, the resident had diagnoses which included, but were not limited to, muscle weakness and difficulty walking. A review of the quarterly Minimum Data Set (MDS), dated [DATE], included the resident had a Brief Interview for Mental Status score of 13 out of 15, which indicated the resident's cognition was intact. A review of the individualized comprehensive care plan (ICCP), dated 4/21/26, included a focus that the resident had the potential to be verbally aggressive related to emotional feelings. Interventions included: Assess the resident's understanding of the situation, allow time for the resident to express self and feelings towards the situation, and when the resident becomes agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, and if response is aggressive, staff to walk calmly away and reapproach later. On 5/15/26 at 12:49 PM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who explained that Resident #81 would sometimes yell at staff, but that he never had any issues with the resident. On 5/15/26 at 12:52 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that Resident #81 could be verbally aggressive towards staff, but that it was important to ensure the resident felt safe in the facility. On 5/15/26 at 1:00 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) #1 who stated Resident #81 would complain about specific CNAs from time to time and that she would change the CNA assignment when that happened. The RN/UM further stated it was important to ensure the resident received the care they deserved and felt safe. On 5/15/26 at 1:02 PM, the surveyor observed the PT enter Resident #81's room. The surveyor overheard the PT apologizing to the resident and stated he should not have talked to him/her that way. On 5/15/26 at 1:06 PM, the surveyor interviewed the PT. When asked what the PT was discussing with the resident, the PT stated the resident told him that he does not say nice things to the resident, which the PT admitted was a fair assessment. The PT then acknowledged that, while he was trying to be direct with the resident, his tone was talking down to the resident and was not appropriate. The PT further explained that it was important to maintain a safe space and to ensure the residents felt comfortable. On 5/15/26 at 1:23 PM, the surveyor interviewed the Director of Rehab (DOR) who stated Resident #81 had behaviors towards staff, but that she would expect staff to respond to the resident in a respectful manner and reapproach the resident, if necessary, as it was sometimes difficult to redirect the resident's behavior. At that time, the surveyor described the interaction between the PT and Resident #81, and the DOR confirmed that the interaction was not professional or respectful to the resident. The DOR also stated that it was important to speak to residents respectfully to ensure the residents were being properly cared for. On 5/15/26 at 1:33 PM, the surveyor interviewed the Director of Nursing (DON) who stated it was important to speak to the residents respectfully to ensure the dignity of the residents as the facility was their home. The DON explained that Resident #81 could be verbally abusive towards staff, but that staff should try to talk through the situation with the resident or step away to get a supervisor. The DON stated that staff should not fight back with the resident as they were expected to respond in a respectful manner. At that time, the surveyor described the interaction between the PT and Resident #81, and the DON confirmed that the PT should not have responded to the resident in that manner, as the tone was not appropriate. On 5/15/26 at 1:53 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated staff should speak to residents in a nice, respectful way to honor the resident's rights. At that time, the surveyor described the interaction between the PT and Resident #81, and the LNHA confirmed that the PT should have spoken to the resident in a more hopeful, upbeat manner, and that if the resident was being verbally abusive towards the PT, he should have respectfully left the room and reapproached the resident later. A review of the Physical Therapist Job Description signed by the PT on 4/16/25, included the following:Maintain professional relationships with co-workers, facility staff, patients, and patient families.Comply with all facility policies and procedures.Maintain a positive work atmosphere by demonstrating and communicating in a professional manner so as to foster positive relations with customers, clients, co-workers, and managers.Adhere to any and all other written and oral policies and procedures. A review of the facility's Resident Rights policy, revised 2/22/24, included, Residents, visitors, and staff will be treated with dignity and respect, and that residents have the right: To be treated with courtesy, consideration, and respect. NJAC 8:39-4.1(a)(12)

Based on observation, interview, and policy review, the facility failed to ensure dumpster lids were kept closed and trash was not on the ground in the dumpster area. This failure had the potential to cause pest infestation or spread of infection affecting all 158 residents. Findings include: During an initial tour of the kitchen on 03/04/25 beginning at 10:42 AM, conducted along with the Dietary Manager (DM) and Regional Food Service Director (RFSD), the three trash and one recycling dumpster were observed. The recycling dumpster lid and the lid of the middle trash dumpster were open. The front trash dumpster was over-filled with trash preventing the lid from closing all the way. There was trash on the ground around all the dumpsters. The DM began picking up trash next to the recycling dumpster and disposing of it in the dumpster. During a concurrent interview, the RFSD stated the trash was due for pick up today and confirmed the lid did not close and two dumpsters were open. The DM and RFSD left the dumpster area without closing the open lids. During an observation of the dumpster area on 03/07/25 at 12:12 PM, conducted along with the RFSD, the three trash and one recycling dumpsters were open. There was a bag of cans on the ground next to the recycling dumpster. The RFSD stated the dumpsters were open and normally should be kept closed. The RFSD confirmed a bag of empty cans was on the ground and should have been placed inside the dumpster. During an interview on 03/07/25 at 12:37 PM, the DM stated some of the kitchen staff were too short to reach the dumpster lid, so they typically left the lid open during the day for easy access and would ensure the lids were closed at the end of the day. The DM stated he instructed the staff who could not reach to leave the bags of cans on the ground next to the dumpster to be put in at the end of the day. Review of the facility policy titled, Maintaining a Clean and Sanitary Dumpster Area, dated 02/12/25, revealed, No loose garbage or food waste should be left outside the dumpster . At the end of each kitchen shift, designated staff will inspect the dumpster area to ensure trash is properly contained [and] the area around the dumpster is free of debris and spills . Pest Control Measures: Keep the dumpster lids closed at all times to prevent pest entry. NJAC 8:39-19.7

Based on observation, interview, and policy review, the facility failed to ensure nine cartons of milk were not expired. Though the milk was discarded prior to meal service, the potential receipt of expired milk by nine residents placed these residents at risk of foodborne illness. Findings include: During an initial tour of the kitchen on [DATE] at beginning at 10:42 AM, conducted along with the Dietary Manager (DM) and Regional Food Service Director (RFSD), the dairy refrigerator with ready-to-serve items prepared for lunch, located at the tray line in the meat kitchen, was observed. In the dairy refrigerator were eight cartons of milk with a sell by date of [DATE] and one carton of milk with a sell by date of [DATE]. The FSD and DM pulled out the nine expired milks from the refrigerator and discarded them. In a concurrent interview, the FSD stated the milk cartons in the dairy refrigerator had been prepared for use during lunch service for residents who did not prefer a kosher diet. She stated a new shipment had just been received, so she was not aware any of the milks were expired and stated they should not be available on the tray line. The DM stated the milk shipment had just come in, so he did not understand why expired milks were being used, and stated the expired milks needed to be discarded. Review of the facility's undated policy titled, Receiving and Inspecting Guidelines, revealed, Rotation: Rotate stock to use older items first . Make a schedule to throw out food on a regular basis . FSD and Cooks check dates and leftovers daily. NJAC 8:,d+[DATE].2(g)

Based on observation, menu review, interview, and facility policy, the facility failed to ensure residents who ate in the second-floor dining room received adequate portion sizes according to the menu. This failure had potential to cause hunger, weight loss, or malnutrition for the 28 residents, out a census of 158, who ate their meals in the second-floor dining room and had orders for regular portions with chopped or regular texture. Findings include: Review of the undated Cedar Unit Assignment Sheet, provided on paper by the facility with the residents who ate in the second-floor dining room circled, revealed 15 residents ate in the second-floor dining room from the Cedar unit. Review of the undated Maple Unit Assignment Sheet, provided on paper by the facility with the residents who ate in the second-floor dining room circled, revealed 17 residents ate in the second-floor dining room from the Maple unit. Review of the facility's Diet Type Report, dated 03/07/25 and provided on paper by the Dietary Manager (DM), 31 of the 32 residents who ate in the second-floor dining room had orders for regular portions at meals. Of those 31 residents, 14 received a regular texture, 14 received a chopped texture. Additionally, two residents received a ground texture and one received a puree texture, and these meals were pre-plated in the kitchen. The 28 residents who received regular or chopped diets had their meals plated at the steam table in the second-floor dining room. Review of the facility's Fall/Winter Week 4 menu, provided on paper by the DM, revealed the following portion sizes for regular and chopped meals on Thursday lunch: -Mashed Potatoes: 1/2 cup (4 ounces (oz)) -California Blend Vegetables: 1/2 cup (4 oz) During an observation of lunch service at the steam table in the second-floor dining room on 03/06/25 beginning at 11:57 AM, Server (S) 1 served 2-oz. portions of mashed potatoes and 2-oz portions of California blend vegetables to 28 residents in the dining room. She did not use two scoops of each item to equal 4-oz. servings. In a concurrent interview, S1 confirmed her scoop sizes for the California vegetable blend and the mashed potatoes were both 2 oz. She stated she did not have any large scoops available on the second floor. Review of the facility's Fall/Winter Week 4 menu, provided on paper by the DM, revealed the following portion sizes for regular and chopped meals on Friday lunch: -Rice Pilaf: 1/2 cup (4 oz) -Italian [NAME] Beans: 1/2 cup (4 oz) During an observation of lunch service at the steam table in the second-floor dining room on 03/07/25 beginning at 12:16 PM, S1 confirmed her scoop sizes for the Italian green beans and rice pilaf were both 2 oz. She stated she tried serve a heaping scoop because she did not have any larger scoop sizes available. S1 did not use two scoops of each item to equal 4-oz servings. In a concurrent interview, S1 stated the portion sizes documented on the menu should have been 4 oz.; however, she did not have 4-oz. scoops available. During an interview on 03/07/25 at 12:37 PM, the DM stated the kitchen had new 4-oz scoops available and he would provide some to the second-floor dining room. The DM stated S1 should have served a 4-oz portion of each starch and vegetable by either using a 4-oz scoop or using two 2-oz scoops. The DM stated some of the residents in the second -floor dining room preferred smaller portions, as larger portions could be overwhelming, but their diet orders were for regular portions. The DM stated he discussed this issue with the Registered Dietitian (RD), who told him the portion size called for on the menu should be served unless there was an order for small portions. During an interview on 03/07/25 at 4:04 PM, the RD stated the issue of preferences of small portions had not been discussed with her and stated the portion size as documented on the menu should be served to meet calculated nutritional needs. Review of the facility's undated policy titled, Proper Portion Sizes revealed, All meals served in the dietary department shall adhere to standardized portion sizes to maintain consistency, meet dietary guidelines, and control food costs. Staff members responsible for meal preparation and service must use standardized measuring tools (such as portion scoops, ladles, etc.) to ensure accuracy . The following portion sizes shall be adhered to for all resident meals: . Starches (Potatoes, Rice, Pasta, Grains, etc.) - 4 oz at both lunch and dinner . Cooked or Marinated Vegetables - 4 oz per serving. NJAC 8:39-17.2

Based on interview, record review, and policy review, the facility failed to ensure psychotropic medication efficacy was monitored and failed to ensure PRN (as needed) antianxiety medications had a stop date including a rational for continuing the PRN medication beyond 14 days for eight of eight residents (Resident (R) 23, R28, R38, R42, R60, R61, R138, and R142) reviewed for unnecessary and/or psychotropic medications from a total survey sample of 34 residents. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of medication. Findings include: 1. Per R28's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 05/05/21 with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions,) Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves,) anxiety disorder, and depressive disorder. Review of R28's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/04/25 and located in the resident's EMR under the MDS tab revealed the facility assessed that the resident did not exhibit mood or behavioral symptoms. R28 received antipsychotic, and antidepressant medication. Review of R28's Care Plan Report located in the residents' EMR under the Care Plan tab, included a care plan for Psychotropic drug use Detail: Potential adverse effects from psychotropic drug use secondary to the use of antidepressant and antipsychotic medications, initiated 05/07/21. The care plan included the interventions as follows: - Administer medication per order. - Always approach in a calm, unhurried manner. Attempt to build a trusting relationship. Provide reassurance that resident is safe. Allow to verbalize feelings/concerns. Assist with problem solving. - Assess for dehydration, dry mouth. -Attempt to identify any triggers or contributing factors to mood changes. Educate staff as able to avoid these triggers as much as possible. -Encourage to verbalize feeling. -Monitor for adverse effects of Med [medication]. -Monitor for any contributing factors to aggression (pain, changes in medical status, change in mental status). - Monitor for S/S [signs and symptoms] depression (self-isolation, crying, tearfulness, decreased appetite, irritability, change in sleep habits, lethargy. - Monitor for therapeutic effect of med. - Monitor for: Movement Disorders/Tardive Dyskinesia Decline in Mood/LOC [level of consciousness] Decline in ADL's [activity of daily living] Urinary retention Dizziness Constipation. - Prior to beginning, explain all TX [treatment] /or procedures in a calm manner. - Provide safety measures at all times. R28's Care Plan Report included a care plan for The resident uses antidepressant medication r/t [related to] Depression,, initiated 05/15/21. The care plan included the interventions as follows: - Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [every shift]. - Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms anti-depressant drugs being given. - Monitor/document/report PRN [as needed] adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activity daily living] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea and vomiting], dry mouth, dry eyes. R28's Care Plan did not include interventions to what target behaviors were treated for antipsychotic and antidepressant medication use. The Care Plan also did not include what nonpharmacological interventions the staff would offer if the target behaviors were observed. R28's Psychiatric Progress Note dated 02/05/25 and located in the residents' EMR under the Prog [Progress] Note tab, included a nurse practitioner's psych [psychotropic] follow up note, which revealed Clinical signs and target symptoms: forgetfulness/memory loss, confusion .ASSESSMENT/PLAN .Always consider supportive and individualized non-pharmacologic interventions, inc [including]: redirection, support/reassurance, comfort measures, reduced environmental stimulation, expression of feelings, family involvement. R28's medication Administration Report for order range 01/01/25 to 03/06/25, documented R28 received phototropic medication and related monitoring by physician's order as follows: - ARIPiprazole (Antipsychotic) Tablet 5 MG [milligram] Give 1 tablet by mouth one time a day for schizophrenia identify and monitor the behavior exhibited for aripiprazole. Start date 10/23/21. - Sertraline HCl (Antidepressant) Tablet Give 75 milligram by mouth one time a day for Depression Sertraline 25 mg-give 3 tabs [tablets]= 75 mg. Start date 11/16/24. - Observe potential side effects of ANTIDEPRESSANTS: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. DOCUMENT IN PROGRESS NOTE IF OBSERVED. every shift. Start date 06/10/21. - Observe potential side effects of ANTIPSYCHOTIC MEDS: Blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, Tardive Dyskinesia. DOCUMENT IN PROGRESS NOTE IF OBSERVED. every shift DOCUMENT IN PROGRESS NOTE IF BEHAVIOR OBSERVED. Start date 06/10/21. - Target Behavior: Agitation and Yelling every shift Document behavior in progress notes every shift Start date 06/14/22. Review of R28's undated admission Record, located in the resident's EMR under the Profile tab revealed that the facility combined two behaviors, Agitation and Yelling, into one monitoring category for two different classes of medications: antipsychotics and antidepressants. It was unclear which target behaviors monitoring were associated with the use of antipsychotic, and which were linked to antidepressant. Additionally, the target behavior monitoring did not record the number of behavior episodes observed during each shift. There was no documentation indicating the nonpharmacological interventions as the nurse practitioner's ASSESSMENT/PLAN were offered to R28. During an interview on 03/07/25 at 10:46 AM, the Director of Nursing (DON) reviewed R28's records and stated that the facility had combined the monitoring of target behaviors for antipsychotic and antidepressant medications, and the nonpharmacological interventions had not been offered. The DON further stated the target behavior monitoring and nonpharmacological interventions would be separated by medication type and included in the care plan. 2. Per R23's undated admission Record, located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 01/09/25 with diagnoses which included anxiety and depression disorder. Review of R23's admission MDS with ARD of 01/16/25 and located in the resident's EMR under the MDS tab revealed the facility assessed that the resident did not exhibit mood or behavioral symptoms. R23 received antidepressant medication. Review of R23's Care Plan Report located in the resident's EMR under the Care Plan tab, included a care plan for Psychotropic drug use Detail: Potential adverse effects from psychotropic drug use secondary to the use of x Antidepressant, initiated 01/17/25. The care plan included the interventions as follows: - Administer medication per order. - Always approach in a calm, unhurried manner. Attempt to build a trusting relationship. Provide reassurance that resident is safe. Allow to verbalize feelings/concerns. Assist with problem solving. - Assess for dehydration, dry mouth. - Attempt to anticipate needs to reduce anxiety. Attempt to keep daily routine as able. Attempt to identify triggers to anxiety, educate staff to avoid these areas. - Attempt to identify any triggers or contributing factors to mood changes. Educate staff as able to avoid these triggers as much as possible. - Dietary consult as needed. - Encourage to verbalize feeling. - 'Evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. - Monitor for adverse effects of Med. - Monitor for any contributing factors to aggression (pain, changes in medical status, change in mental status.) - Monitor for S/S depression (self-isolation, crying, tearfulness, decreased appetite, irritability, change in sleep habits, lethargy. - Monitor for S/S of anxiety (fidgeting, easily annoyed, repetitive speech/behaviors. Intervention indicated with least restrictive measure that is effective. Keep MD [medical doctor] informed of concerns. - Monitor for therapeutic effect of med. - Notify physician of decline in ADL or mood/behavior related to dosage change. - Prior to beginning, explain all TX [treatment] /or procedures in a calm manner. - Provide patient education to risks and benefits of medications as needed. - Provide safety measures at all times. - Reduce environmental noise/distractions to facilitate sleep. - Report to physician signs of adverse reaction such as decline in mental status, decline in positioning/ambulation ability, lethargy, complaints of dizziness, tremors. R23's Care Plan Report included a care plan for Impaired Coping, initiated 01/16/25, including the interventions as follows: - Monitor for signs / symptoms of depression. - Evaluate sleep pattern. R23's Care Plan did not include interventions to what target behaviors he was treating for antidepressant medication use. And what nonpharmacological interventions the staff would offer if the target behaviors were observed. R23's Psychiatric Progress Note located in the residents' EMR under the Prog Note tab, included a nurse practitioner's psych [psychotropic] follow up note, dated 03/05/25 of Clinical signs and target symptoms: forgetfulness/memory loss, confusion, anxiety, verbal aggression .ASSESSMENT/PLAN .Always consider supportive and individualized non-pharmacologic interventions, inc [include] redirection, support/reassurance, comfort measures, reduced environmental stimulation, expression of feelings, family involvement. R23's medication Administration Report for order range 02/01/25 to 03/04/25, documented R23 received phototropic medication and related monitoring by physician's order as follows: - buPROPion HCl (antidepressant) Oral Tablet 75 MG (Bupropion HCl) Give 75 mg by mouth one time a day for depression. Start date 01/10/25. - Mirtazapine (antidepressant) Tablet 30 MG Give 1 tablet by mouth at bedtime for insomnia. Start date 01/10/25. - Observe potential side effects of ANTIANXIETY MEDS: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucination. DOCUMENT IN PROGRESS NOTE IF OBSERVED every shift. Start date 01/10/25. - Target Behavior: Hallucination, Delusion, physical behavior towards others, verbal behavior (screaming at others, cursing at others), behavior not directed towards others (screaming, yelling w/ no apparent reason), Rejection of care (medication, care, and treatment), wandering every shift Document behavior in progress notes every shift. Start date 01/10/25. - ALPRAZolam (antianxiety) Oral Tablet 0.25 MG (Alprazolam) Give 0.25 mg by mouth every 12 hours as needed for anxiety for 90 Days. Start date 01/10/25. The medication Administration Report documented R23 received on 2/14/25 at 10:17 PM. A review of R23's entire EMR revealed that the facility did not monitor hours of sleep for antidepressant use to treat insomnia. It was unclear which target behaviors monitoring were associated with the use of antianxiety and which were linked to antidepressant. Additionally, the target behavior monitoring did not record the number of behavior episodes observed during each shift. There was no documentation indicating the non-pharmacological interventions as the nurse practitioner's ASSESSMENT/PLAN was offered to R23. During an interview on 03/07/25 at 10:46 AM, the DON reviewed R23's records and stated that the facility had combined the monitoring of target behaviors for antidepressant and antianxiety medications, and the non-pharmacological interventions had not been offered. The DON stated if antidepressant medication were used to treat insomnia, the hours of sleep would be monitored. The DON further stated the target behavior monitoring and non-pharmacological interventions would be separated by medication type and included in the care plan. 3. Review of R60's undated admission Record from the electronic medical record (EMR) under the Profile tab showed a facility admission date of 09/14/19 with medical diagnoses that included dementia, hemiplegia/hemiparesis after cerebral infarct (stroke), atrial fibrillation, depression, psychosis, mood disorder, and pseudobulbar affect. Review of R60's Order Summary from the EMR under the Orders tab revealed physician orders for: -Depakote sprinkles (a mood stabilizer medication)125 milligrams (mg, generic name divalproex) each morning and bedtime for mood disorder, ordered 01/27/25 -Escitalopram (an antidepressant medication) 5mg daily for depression, start 12/21/22 -Quetiapine (an antipsychotic medication) 12.5mg three times a day for delusional disorder ordered 02/11/25 -Target Behavior: monitor for verbal behavior (yelling, crying), Rejection of care every shift and document if behavior observed in progress notes every shift, ordered 03/25/21. -Observe potential side effects of antidepressants: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, nausea/vomiting, dry mouth, dry eyes. Document in progress note if observed every shift -Observe potential side effects of antipsychotic meds: Blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, Tardive Dyskinesia. Document in progress notes if observed every shift. Document in progress note if behavior observed. -Observe potential side effects of mood stabilizer meds: Abdominal pain, ataxia, frequent urination, nausea, vomiting, thirsts, tremors, weight loss/gain. Document in progress note if observed. Review of R60's Care Plan located in the EMR under the Care Plan tab revealed focus areas for: -Verbal/physical agitation/aggression/ socially inappropriate/disruptive behavior related to (nothing added); initiated on 01/31/22 -The resident uses psychotropic medications related to behavior management; initiated on 11/22/20 Further review of the Care Plan revealed interventions to monitor for psychotropic medication side effects, however, no target behaviors were identified for each psychotropic medication to enable efficacy monitoring. 4. Review of R138's undated admission Record from the EMR under the Profile tab showed a facility admission date of 08/21/24 with medical diagnoses that included unspecified dementia with other behavioral disturbances and vascular dementia with other behavioral disturbance. Review of R138's Order Summary from the EMR under the Orders tab revealed: -Divalproex sodium 125 mg twice a day for mood disorder, ordered 11/26/2024 -Risperidone Tablet (an antipsychotic medication) 0.5 mg twice a day for dementia with psychosis, ordered 11/15/2024 -Observe potential side effects of antipsychotic meds: Blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, Tardive Dyskinesia. Document in progress note if observed every shift. Document in progress note if behavior observed, initiated 02/05/25. -Observe potential side effects of mood stabilizer meds: Abdominal pain, ataxia, frequent urination, nausea, vomiting, thirsts, tremors, weight loss/gain. Document in progress note if observed, initiated 08/21/24. -Target Behavior: Hallucination, Delusion, physical behavior towards others, verbal behavior (screaming at others, cursing at others), behavior not directed towards others(screaming, yelling w/ no apparent reason), Rejection of care (medication, care and treatment), wandering every shift Document behavior in progress notes every shift; ordered 02/05/25. Review of R138's Care Plan located in the resident's EMR under the Care Plan tab revealed no identified behaviors related to the use of the mood stabilizer or antipsychotic medications to enable monitoring for medication efficacy. 5. Review of R142's undated admission Record from the EMR under the Profile tab showed a facility admission date of 11/27/24 with medical diagnoses that included unspecified dementia without behavioral or psychotic disturbance and depression. Review of R142's Order Summary from the EMR under the Orders tab revealed: -Clonazepam (an anxiolytic medication) 0.5 mg three times daily for anxiety, ordered 02/07/25 -Divalproex sodium 250 mg three times a day for mood disorder, ordered 01/08/25 -Mirtazapine (an antidepressant medication) 7.5 mg at bedtime for depression, ordered 02/04/25 -Risperidone 1 mg twice a day for psychosis, ordered 02/20/25 -Observe potential side effects of antidepressants: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in activities of daily living ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, nausea/vomiting, dry mouth, dry eyes. Document in progress note if observed every shift. -Observe potential side effects of antipsychotic meds: Blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, Tardive Dyskinesia. Document in progress note if observed every shift. Document in progress note if behavior observed. -Observe potential side effects of mood stabilizer meds: Abdominal pain, ataxia, frequent urination, nausea, vomiting, thirsts, tremors, weight loss/gain. Document in progress note if observed every shift. -Target Behavior: Hallucination, Delusion, physical behavior towards others, verbal behavior (screaming at others, cursing at others), behavior not directed towards others(screaming, yelling with no apparent reason), Rejection of care (medication, care and treatment), wandering every shift. Document behavior in progress notes every shift, ordered 02/05/25. During an interview on 03/07/25 at 10:35 AM regarding target behaviors for each psychotropic medication, the DON stated, Right now, we do not have target behaviors for each medication. Review of the facility policy titled Use of Psychotropic Medication, reviewed 01/23/25, revealed: .Procedure: 1. Psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to drugs in the following categories: a. Anti-psychotic b. Anti-depressant c. Anti-anxiety; and d. Hypnotic 2. Diagnoses which may require antipsychotic medication use and do not require daily monitoring of target behaviors: a. Schizophrenia b. Schizo-affective disorder c. Delusional disorder d. psychotic mood disorders, including mania and depression with psychotic features e. acute psychotic episodes f. brief reactive psychosis g. Schizophreniform disorder h. atypical psychosis i. Huntington's disease j. Tourette's disorder k. organic mental syndromes (i.e., delirium, de entia, and other cognitive disorders) with associated psychotic and/or agitated behaviors which are causing the resident to exhibit behavior such as screaming, yelling, pacing, or to experience psychotic symptoms (hallucinations, paranoia, delusions) which may or may not be danger us to him/herself or others but are causing the resident distress or impairment in functional capacity. 2. Diagnoses which may require anxiolytic/sedative se and do not require daily monitoring of targeted behaviors: a. Generalized anxiety disorder b. Panic disorder c. Symptomatic anxiety that occurs in resident with another diagnosed psychiatric disorder 3. Sample targeted behaviors for antipsychotic medication or anxiolytic/hypnotics use: Wringing of hands Hitting Grabbing and hurting self or others Throwing objects Making strange noises Biting Disrobing Kicking Scratching Repetitive statements Tension Cursing Pushing others Assaultiveness [sic] Screaming continuously Yelling continuously Crying continuously Negativism Hallucinations If the targeted behaviors being monitored for antipsychotic medication use do not indicate the resident is harmful to self or others, the physician should document in his progress notes that the medication is needed to increase the functional status of the resident. 6. Review R38's undated admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and depression disorder. Review of R38's Care Plan, dated 08/08/24 and located in the resident's EMR under the Care Plan tab showed R38 was care planned for verbal and physical, aggression, and disruptive behavior such as screaming and yelling. Review of R38's quarterly MDS with and ARD of 12/16/24 and located in the resident's EMR under the MDS tab showed the facility assessed R38 to have a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident was moderately cognitively impaired. The MDS also indicated the resident had other behavioral symptoms not directed towards. Review of R38's Physician Order, dated 02/27/25 and located in the resident's EMR under the Orders tab showed to administer lorazepam (benzodiazepine to treat anxiety) 0.5 mg (milligrams) by mouth every six hours as needed for anxiety. Further review showed no stop date along with rationale to continue as needed usage. 7. Review of R42's undated admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and bipolar disorder. Review of R42's Care Plan, dated 05/10/24 and located in the resident's EMR under the Care Plan tab showed R42 was care planned with a problem of mood related to the usage or side effects of medication. Review of the R42's quarterly MDS with and ARD of 11/25/24 showed the facility assessed R42 to have a BIMS score of 12 out of 15 which indicated the resident was moderately cognitively impaired. Review of R42's Physician Order, dated 03/04/25 and located in the resident's EMR showed to give lorazepam 0.5 mg tablet by mouth every 12 hours as needed for anxiety. Further reviewed showed no stop date. 8. Review of R61's undated admission Record, located in the resident's EMR under the Profile tab showed R61 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and bipolar disorder. Review of R61's annual MDS with an ARD of 12/04/24 showed the facility assessed R61 to have a BIMS score of 99 which indicated R61 could not participate in the assessment and was severely cognitively impaired. R61 was assessed to have had behaviors towards others such as hitting, kicking, pushing, and scratching during the assessment period. Review of R61's Care Plan dated 12/12/23 and located in the resident's EMR under the Care Plan tab showed R61 had aggression both verbal and physical towards staff and others. Review of R61's Physician Orders, dated 02/11/25 and located in the resident's EMR under the Orders tab showed to administer lorazepam 1mg tablet by mouth every eight hours as needed for anxiety for 60 days. Further review of the electronic record revealed no rationale on why to continue lorazepam for 60 days. During an interview on 03/07/25 at 1:03 PM, when brought to the attention of the Nurse Practitioner of the missing stop dates for R38's and R42's PRN lorazepam, the Nurse Practitioner confirmed there were no stop dates for the PRN lorazepam. Further interview revealed the Nurse Practitioner confirmed there was no rationale to continue past 14 days for R61's PRN ordered lorazepam. Review of the facility's policy titled Use of Psychotropic Medication revised 03/2019 showed .Psychotropic PRN [as needed] or Excluding antipsychotics. Time Limitations: 14 days ii. Exception: Order may be extended beyond 14 days if the physician believes it is appropriate to extend the order. iii. Physician should document that rational of the extended time period in the medical record and indicate the specific condition . NJAC 8:39-5.1(a) NJAC 8:39-29.3

Based on policy review, record review, and staff interviews, the facility failed to develop a person-centered comprehensive plan of care for one of 34 sample residents (Resident (R) 41) regarding a continuous blood glucose monitor; or measurable goals or objectives regarding behaviors for two of seven residents (Resident (R) 60 and R138) reviewed for psychotropic medications. These failures placed the residents at risk of unmet care needs pertaining to glucose management and behavior management. Findings include: 1. During an interview on 03/05/25 at 10:27 AM, R41 revealed she had diabetes. R41 stated she received insulin and the staff administered the insulin. R41 had a Freestyle Libre blood glucose monitor (a continuous blood glucose monitor) that staff used to monitor her blood glucose levels. During an observation of insulin administration for R41 and interview with Licensed Practical Nurse (LPN) 1 on 03/06/25 at 12:45 AM revealed R41's blood glucose had been checked earlier; she had a continuous blood glucose meter and used a special phone to check the blood glucose. LPN1 was not sure who applied and/or changed the continuous blood glucose meter. Review of R41's Clinical Census tab found in her electronic medical record (EMR) revealed she had been admitted to the facility on [DATE]. Review of R41's diagnoses found under the Clinical Diagnosis tab in her EMR revealed diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified. Review of R41's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date of 01/09/25 revealed she had a Brief Interview for Mental Status of 15. That indicated her cognition was intact. Review of R41's March 2025 Medication and Treatment Administration Records (MAR/TAR), located under the EMR Physicians Orders tab, revealed PATIENT HAS BLOOD SUGAR SENSOR TO LEFT ARM FOR BLOOD SUGAR CHECKS every shift -Start Date-02/09/2025 2300 [11:00 PM]. There were no further orders on when to change the continuous glucose monitor. Review of R41's 01/15/25 Comprehensive Care Plan found under the Care Plan tab in the EMR revealed no focus area, goal, or interventions about the use of a continuous glucose monitor. Observation and interview on 03/07/25 at 12:45 PM with R41 revealed she had a Freesytle Blood Glucose monitor on her left upper arm. R41 said that her significant other changed it every two weeks. The staff did not do anything with the monitor. R41 would check her blood glucose and tell them the reading. During an interview on 03/07/25 at 1:21 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) agreed there had been no monitoring of R41's Free Style Libre glucose monitor. They were aware her significant other changed the monitor when it was needed. During an interview on 03/07/25 at 1:32 PM, the Minimum Data Set Coordinator (MDSC) confirmed there was no information regarding R41's care plan about her use of a continuous blood glucose monitor. 2. Review of R60's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included dementia, hemiplegia and hemiplegia following cerebral infarct (ischemic stroke, a condition where blood flow to the brain is blocked), atrial fibrillation, depression, psychosis, mood disorder, pseudobulbar affect (a neurological disorder characterized by uncontrollable episodes of laughing or crying that are often inappropriate or disproportionate to the situation), and pain. Review of R60's Care Plan from the EMR Care Plan plan tab showed a focus of Verbal/physical agitation/aggression/socially inappropriate/disruptive behavior related to [nothing was filled in] initiated on 01/31/22 with a goal of I will have fewer episode of behavioral symptoms through review date initiated: 01/31/22, revised on 07/13/22, with a target date of 05/27/25. Further review of R60's Care Plan showed no baseline of how many episodes occurred when initiated, or a quantitative amount for any of the reviews since 01/31/22 to enable a baseline to ensure the goal was achieved or required adjustments. 3. Review of R138's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included dementia / vascular dementia with other behavioral disturbance, glaucoma, hypertension, and high cholesterol. Review of R138's Care Plan from the EMR Profile tab showed a focus of Resistive care related to change in routine, cognitive impairment, unfamiliar environment/caregiver, dx [diagnosis] of Dementia initiated on 08/29/24; with a care plan goal of I will have fewer episode [sic] of behavioral symptoms through review date initiated on 08/29/24 with a target date of 04/22/25. Further review of R138's Care Plan showed no baseline of how many episodes occurred when initiated, or a quantitative amount for any of the reviews since initiation to enable a baseline to ensure the goal was achieved or required adjustment. During an interview on 03/07/25 at 4:29 PM, the Director of Nursing (DON) stated, The goals needed to be reassessed to ensure there was a baseline to ensure a goal is measurable. Review of the facility policy titled Interdisciplinary Care plans, reviewed 01/21/25, revealed, .4. The care plan will be individualized and will include problems, goals and approaches that reflect the resident's uniqueness and idiosyncrasies. .6. Care plans will be reviewed and adjusted as needed and on a quarterly basis by any member of the IDT [interdisciplinary team] to ensure that the most current and comprehensive plan of care is followed. Review of the October 2024 Resident Assessment Instrument (RAI) Manual stated on page 4-5: Begin to develop an individualized care plan with measurable objectives and timetables to meet a resident's medical, functional, mental and psychosocial needs as identified through the comprehensive assessment. Page 4-8 stated: . the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Page 4-10 stated: 1. Assisting the resident in achieving their goals. 2. Individualized interventions that honor the resident's preferences. 7. Evaluating treatment of measurable objectives, timetables and outcomes of care. Page 4-11 stated: The following key steps and considerations may help the IDT develop the care plan after completing the comprehensive assessment: 1) Care Plan goals should be measurable. The IDT may agree on intermediate goal(s) that will lead to outcome objectives. Intermediate goal(s) and objectives must be pertinent to the resident's goals, preferences, condition, and situation (i.e., not just automatically applied without regard for their individual relevance), measurable, and have a time frame for completion or evaluation. NJAC 8:39-11.2(e) thru (i) NJAC 8:39-27.1(a)

Based on observation, interview and review of the facility's policy, the facility failed to ensure one of four soiled utility rooms (400 Unit) was maintained in a sanitary condition. This failure placed all residents on the 400 Unit at risk for not having a safe and clean homelike environment. Findings include: Observation on 03/04/25 at 11:55 AM of the 400 Unit's soiled utility room revealed the soiled utility room had a bag of trash on the floor next to the trash receptacle. Observation on 03/05/25 at 9:48 AM of the 400 Unit's soiled utility room revealed, Housekeeper (HK) 1 placed a bag of trash on the floor next to the trash receptacle because the trash receptacle appeared full. Observation on 03/05/25 at 9:53 AM of the 400 Unit's soiled utility room revealed two bags of soiled laundry on the floor. During an observation and interview on 03/05/25 at 9:55 AM, the Housekeeping Director (HD) stated there was not supposed to be anything on the floor, it was not acceptable. The HD observed the laundry bin and stated it was not full and picked up the bags of soiled laundry and placed them in the laundry bin. The HD stated anytime housekeeping staff went into the soiled utility room, it was her expectation they check for laundry and trash being on the floor. The HD confirmed the Review of the facility's policy titled, Basic Cleaning: Trash Removal revised 03/2020 showed .place bag (trash) in proper receptacle on utility cart or trash bin . NJAC 8:39-31.4(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure the call bell was accessible for one of 36 residents (Resident (R) 32) observed in the Initial Pool. This failure placed R32 at risk of injury or distress when he could not access the call bell to alert staff of an emergency or unmet needs. Findings include: Review of R32's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he admitted on [DATE] with diagnoses including dementia and heart disease. Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/25, located under the MDS tab of the EMR, revealed he scored eight out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. Per the MDS, R32 did not exhibit mood or behavioral symptoms. R32 had no impairment of his functional range-of-motion in his upper extremities. Review of R32's Care Plan, dated 11/03/23 and located under the Care Plan tab of the EMR, revealed, I am at risk for falls because I am on a psychoactive medication, I am weak, I have unsteady gait. The goals included, I will verbalize understanding of the need to call for assistance through review date. The approaches included: Call bell within reach and Please remind me or encourage me to use my call bell. During an observation in R32's room on 03/04/25 at 1:58 PM, R32 was lying in bed in his room and the call bell was on the nightstand, approximately five feet away to his left side. R32 stated he sometimes used the call bell but could not reach where it was located. During an observation on 03/05/25 11:45 AM in R32's room, R32 was lying in bed and the call bell was again on top of the nightstand, approximately five feet away from him. R32 stated, I'd like to have it over here; I should have it. R32 stated he could not reach the call bell and needed to have it closer to his right side. During an observation in R32's room and concurrent interview on 03/05/25 at 11:54 AM, Certified Nursing Assistant (CNA) 2 confirmed the call bell was not within R32's reach and was on the wrong side for him to be able to use it. CNA2 stated R32 could use his call bell but needed it closer to his right side so he could use his right hand. CNA2 stated the call bell should be within his reach at all times. During an interview on 03/07/25 at 10:45 AM, Unit Nurse 2 stated R32's call light should be in his reach at all times, and she would ensure staff were educated to place call lights within reach of the residents. Review of the facility policy titled, Call Bells, dated 01/23/25, revealed, Policy: All residents will have a call bell within reach . Procedure: When getting a resident in a chair or in bed it is imperative that the call bell is in reach and functioning. NJAC 8:39-4.1(a)11

Based on observation, interview, and review of manufacturer's instructions, the facility failed to ensure that one of one Licensed Practical Nurse (LPN) (LPN1) observed for insulin administration had primed an insulin pen prior to dialing the ordered dose for Resident (R) 41. This failure had the potential to reduce the insulin dose which could have affected R41's blood glucose. Findings include: Review of the manufacturer's INSTRUCTIONS FOR USE HUMALOG ([NAME]-ma-log) KwikPen(R) (insulin lispro) revealed, Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Observation and interview with LPN1 on 03/06/25 at 12:45 PM during insulin administration for R41 revealed LPN1 retrieved a new Humalog insulin pen from the medication storage room. LPN1 put a new needle on the pen and dialed the pen to six units of insulin. Just prior to her administering the insulin, the surveyor asked if she had to prime the pen prior to dialing the ordered insulin dose. LPN1 stated she was not sure and then dialed the pen to ten units and asked if that was the correct amount. When the surveyor asked her if that was the recommended dose to prime the insulin pen needle she answered, is it one unit? The surveyor said No, it is two units. LPN1 then primed the insulin pen with two units, dialed the amount of six units, and administered R41 her insulin. Review of R41's Clinical Census tab found in her electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Review of R41's diagnoses found under the Clinical Diagnosis tab in her EMR revealed diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified. During an interview on 03/06/25 at 1:20 PM, the Director of Nursing (DON) stated that the nurses have all been educated on using insulin pens and about priming the insulin pen first. NJAC 8:39-27.1(a) NJAC 8:39-29.2(d)

Based on observations, record reviews, and interviews, the facility failed to ensure one of five residents (Resident (R) 68) reviewed for Activities of Daily Living (ADL) out of 34 sampled residents received timely incontinence care. This failure placed the resident at an increased risk for skin breakdown, urinary tract infections, or an undignified existence. Findings include: Review of the facility's policy titled, ADL [activity daily living] policy, revised 09/01/13, reviewed 01/23/25, instructs care givers refer to the nurses' instructions on resident's electronic record for ADL needs and assistance required. Per R68's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 04/20/21. Review of R68's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/09/25, located in the resident's EMR under the MDS tab, revealed the facility assessed R68 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated the resident was assessed to not have any behaviors, was always incontinent with bowel and bladder, did not walk, required set up or clean up assistance (helper sets up or cleans up, resident completes activity) for oral hygiene, substantial to maximal assistance (help does more than half of the effort) for roll left and right on bed, and dependent (helper does all the effort) for sit to lying on bed, chair to bed transfer, dressing and toileting. Review of R68's Care Plan Report located in the resident's EMR under the Care Plan tab revealed The resident has an ADL self-care performance deficits as evidenced by requiring: (including bed mob [mobility], transfer, toileting, eating, dressing, personal hygiene and ambulation,) initiated 05/02/22, included the following interventions: - Provide / Encourage assist in ADL's with (specify: 2 person). Hoyer lift for transfers. - Resident prefers to be washed/showered and changed/toileted at 10 am. at times refuses to be changed at this time despite encouragement. Staff will reattempt until resident ready to perform morning ADLs. - Resident refuses to be toileted/changed during the night shift. Prefers door closed at all times, does not want staff in her room at night. R68's Care Plan Report included a care plan for Personalized Care, Initiated 08/02/22, the care plan included all the following interventions: - Choosing bed time: Very important to Resident. - Resident prefers to not be changed/refuses care between the hours of 9pm /bedtime & 9am/after breakfast. - Resident prefers/refuses to not have anyone enter her room between the hours 9pm/bedtime and 8am. - Resident wishes for the Nursing Aides to schedule and coordinate times with the resident when care can be provided. Observation and interview on 03/04/25 at 12:29 PM, R68 was observed sitting on bed with a facility gown on, and she had face make up on. R68's tray table in front of her had a pink square plastic container with a small white towel and soapy water inside. R68 stated staff changed her brief last night at around 8:00 PM to 8:30 PM, and she had not been changed since. The resident stated she had a wet brief on (during the interview) and she had been sitting in the wet brief since last night. R68 further stated I was done with this basin from ten o'clock until now it is still sitting here.this is really typical every day and no one comes in to get me changed. I have to wear a diaper because I cannot walk, and I can't get to the bathroom. In the morning, I am sitting in a soaked diaper, I am on diuretics, so I urinate more. R68 looked and sounded upset and stated one activity staff came to invite her to join a lunch celebration on the second-floor activity room today. R68 stated Look at me, I cannot go like this. R68 stated it was a big problem to get ready in the morning and this was not the first time she missed activities, and she also had missed doctor's appointments in the past because no one assisted her to be ready on time. R68 stated she was always the last one the aides came to assist in cleaning up and to get dressed. R68 stated she had a small abrasion near her buttock, thigh area. When wet, sometimes she felt a bit of pain before. Staff gave her a pad to protect it from getting wet in the past. On 03/04/25 at 1:18 PM, Certified Nursing Assistant (CNA) 5 was observed to answer R68's call light, CNA5 and another CNA entered R68's room for a long time. On 03/04/25 at 4:49 PM, R68 was observed dressed and sitting in her wheelchair in her room near the window. When asked, R68 stated CNA5 came to respond to her call light and changed her when this surveyor left her room on 03/04/2025 at 1:17 PM. R68 stated however she did not get help to be dressed and transferred to her wheelchair until around 2:30 PM. R68 stated her day had just begun from then. When asked, R68 stated she did not press call light again after CNA5 left around 1:30 PM, she just waited, she thought the aides were busy. And when they have time, they would come and help her to get dressed. R68 was in her wet brief from the night before her bedtime until the next day on 03/04/25 at 1:17 PM. R68 did not get dressed until 2:30 PM. Observation was conducted on 03/05/25 from 9:25 AM to 12:20 PM outside of R68's room. At 9:35 AM, CNA6 knocked on R68's door and asked, are you done with your tray? CNA6 entered R68's room and brought out breakfast tray. At 11:03 AM, R68 had a female visitor. At 11:10 AM, R68's visitor left. At 11:44 AM, CNA5 knocked on R68's door to answer the call light instantly, and CNA5 was at R68's doorway and told R68 that she would be back in 15 minutes. At 11:46 AM, CNA5 and CNA6 knocked on R68's door and entered to change her. At 12:07 PM, CNA5 and CNA6 exited R68's room. During an immediate interview with both CNAs, CNA5 stated she delivered breakfast to R68 around 8:30 AM and she prepared a basin to set R68 up for oral and face hygiene at 10:30 AM. CNA5 stated she came back to change R68's brief and provide peri care around 11:15 AM to 11:30 AM. CNA 5 stated R68 usually likes to sit in her wheelchair after cleaning up, but she preferred to stay in bed that day. R68 was in her wet brief from the night before bedtime until the next day 03/05/25 at 11:46AM. During an interview on 03/06/25 at 10:00 AM, CNA4 confirmed R68 had not been changed since last night. CNA4 stated she delivered breakfast to R68 at 8:00 AM and R68 told her she had a doctor's appointment that day at 9:00 AM. When asked, it was already 10:00 AM now, did R68 miss her appointment? CNA4 said, Yes, that is what she said but she could still go. During an observation on 03/06/25 at 10:04 AM, CNA4 knocked on R68's door and entered to change her and CNA1 entered the room one minute later. At 10:19 AM, CNA1 and CNA4 came out of R68's room and talked to Licensed Practical Nurse (LPN) 6. During an observation in R68's room on 03/06/25 at 10:21 AM, LPN6 applied Dermaseptin Ointment (barrier cream) and formed patch to R68's left buttock to her inner thigh area. R68's skin had a patch of scattered redness and whiteness around 10 centimeters (cm) by 10 cm. It presented with a history of open and healed skin. LPN6 stated R68 currently had no skin opening, the care was for prevention. LPN6 stated R68 used to have scattered open rashes in that area about a month ago, because R68 had diarrhea related to her bowel regiment, and the physician already changed the order. During the observation when asked, R68 said her doctor's appointment was at 11:30 AM that day. On 03/06/25 at 10:37AM, CNA1 and CNA4 completed the care and left R68's room. Review of R68's Progress Note, under EMR Progress Note, included an APN [advance practice nurse] PROGRESSNOTES, dated 01/30/25 at 2:43 PM. The progress note documented the physicians - attending visited R68 to follow up chief complaint of blood on wash cloth. The after-visit progress note documented the following: . Patient was requesting to reevaluate her again for possible perineal bleed. She reports taking shower today and no bleeding noted. Upon eval [evaluation], noted small skin opening at her sacrum. Foam patch was applied by unit manager. She does have rash in her perineal, currently uses antifungal. No additional skin opening or discharge noted. Interventions: Sacral ulcer: noted small skin opening, foam patch applied, rx [prescription] wound team to follow, monitor sx [symptoms] Candidiasis: continue nystatin 100000 U/gm [units per gram] q [every] bid [two times a day], monitor sx [symptoms] During an interview on 03/06/25 from 3:32 PM to 4:00 PM with Unit Nurse 3 and R68 in R68's room, R68 stated that the CNAs usually set her up to self-clean her upper body after breakfast, but by the time they came back to change her briefs and clean her bottom, it was around noon or sometimes 2:00 PM. R68 stated she did not want to be in a wet diaper the whole night until the next day until noon or 2:00 PM each day. R68 stated she preferred to get changed after breakfast before setting up for upper body hygiene cleaning. Unit Nurse 3 stated she would revise R68's personalized care plan for the care for the next day. NJAC 8:39-4.1(a)22 NJAC 8:39-27.1(a) NJAC 8:39-27.2(h)

Based on record reviews and interviews with residents and staff, the facility failed to ensure one of 34 sample residents (Resident (R) 68) was provided with the opportunity to review her care plan, medication list and express her concerns and needs during a quarterly care conference. This failure has resulted in care not being tailored to R68's needs, as the care plan was not updated accordingly. Findings include: Review of the facility's policy titled Interdisciplinary (IDT) Care Plans, revised 03/08/23, outlined the care planning guidelines for the IDT team. These guidelines aim to address the individual physical, mental, emotional, psychological, social, spiritual, and medical needs of each resident. The policy details the following procedures: - An interdisciplinary approach will be followed during the formulation of the comprehensive care plan. The resident and/or family and, /or significant other and the whole interdisciplinary team will meet to discuss problems identified, formulate goals that are measurable and attainable and identify approach to be followed in attaining the goals set forth for the resident during an interdisciplinary care plan meeting. - The care plan will be individualized and will include problems, goals, and approaches that reflect the resident's uniqueness and idiosyncrasies. - IDT meeting is then scheduled with resident and or/family member per their preference, plan of care is reviewed; quarterly meetings will be scheduled thereafter or as requested/needed. - Care plans will be viewed and adjusted as needed and on a quarterly basis by any member of the IDT to ensure that the most current and comprehensive plan of care is followed. Per R68's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 04/20/21. Review of R68's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/09/25, located in the resident's EMR under the MDS tab, revealed the facility assessed R68 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also revealed R68 did not present behavior symptoms, was always incontinent with bowel and bladder did not walk, required set up or clean up assistance (helper sets up or cleans up, resident completes activity) for oral hygiene, substantial to maximal assistance (help does more than half of the effort) for roll left and right on bed, and dependent (helper does all the effort) for sit to lying on bed, chair to bed transfer, dressing and toileting. Review of R68's Care Plan Report, located in the resident's EMR under the Care Plan tab, revealed The resident has an ADL [Activities of Daily Living] self-care performance deficits as evidenced by requiring: (including bed mob, transfer, toileting, eating, dressing, personal hygiene and ambulation,) initiated 05/02/22, included the following interventions: - Provide/Encourage assist in ADL's with (specify: 2 person). Hoyer lift for transfers. Initiated 05/02/22. - Resident prefers to be washed/showered and changed/toileted at 10 am at times refuses to be changed at this time despite encouragement. Staff will reattempt until resident ready to perform morning ADLs. Initiated 05/02/22. - Resident refuses to be toileted/changed during the night shift. Prefers door closed at all times, does not want staff in her room at night. Initiated 05/02/22. R68's Care Plan Report included a care plan for Personalized Care, Initiated 08/02/22, the care plan included all the following interventions: - Choosing bedtime: Very important to Resident. Initiated 08/05/22. - Resident prefers to not be changed/refuses care between the hours of 9pm /bedtime & 9am/after breakfast. Initiated 08/05/22. - Resident prefers/refuses to not have anyone enter her room between the hours 9pm/bedtime and 8am. Initiated 08/05/22. - Resident requests that anyone who wishes to enter her room knocks first, state their name, and wait for the resident to say it is ok to enter the room. Initiated 08/05/22. - Resident wishes for the Nursing Aides to schedule and coordinate times with the resident when care can be provided. Initiated 08/05/22. - Resident would like to be part of the discussion and decision making regarding her care and her mediations. Initiated 08/05/22. R68's records included an IDT -Team Conference note, dated 01/13/25 at 10:03 AM, under the EMR Assessment tab. The quarterly IDT- Team conference note documented the participants included R68, Unit Nurse 3, Social Service Assistant (SSA,) Activity Director, and a therapist from the rehabilitation department, included the following: - The conference note under nursing, documented Resident remains stable this quarter. Full code with POLST [Physician Orders for Life-Sustaining Treatment] in place. No recent hospitalization s, no change in medications. Skin remains intact, no falls. Lorazepam available as needed when resident request it during anxiety episodes. Does not report pain in the past 5 days. Resident requires extensive assistance for ADLS. Resident is currently taking Bactrim DS 800-160mg for UTI [urinary tract infection] for 3days. - The conference note under family/patient concerns documented No concerns at this time. On 03/06/25 from 3:32 PM to 4:00 PM, during the interview with the unit manager (Unit Nurse 3) and R68 in R68's room: Unit Nurse 3 reminded R68 about her quarterly care conference on 01/13/25. R68 stated that she thought the conference was meant to address her concerns, she was not aware it was her quarterly care conference, and she felt that the entire conference was full of arguments about her concerns. R68 stated she would like all the opportunities to discuss her care and goals, including the care conference. R68 would like to know what medication she was taking and why. R68 stated, for example, a few weeks ago, she was on three different kinds of bowel regimen medication, which caused her to have lots of diarrhea. R68 said if someone explained to her what medication she was taking, her diarrhea would be prevented. R68 reviewed her Personalized Care care plan and stated she did not know there was a care plan for her; she stated the care plan was accurate, that she wanted to have a good night's sleep, and did not want her brief changed after 9:00 PM and before 9:00 AM because of her personal preference. However, she said the Certified Nursing Assistant (CNA) usually set her up to self-clean her upper body after breakfast, but by the time they came back to change her briefs and clean her bottom, it usually was around noon or sometimes not until 2:00 PM. R68 said she did not want to be in a wet diaper the whole night until the next day noon or 2PM each day. R68 stated she would like to add to her care plan the following: - Get her brief change after breakfast first before setting up for her to self-clean her upper body. - Have a nurse to go through her medication list to explain to her what she is taking. - Change her social service from Social Service Assistant (SSA) to Social Service Director (SSD). - Have a counsel for her life trauma about once or twice a week for longer time. Unit Nurse 3 stated during each care conference the medication list and care plans should be reviewed, and the resident's care, goals, special needs or if any issues or changes should be discussed, and the care plan should be updated based on the changes after care conference. Unit Nurse 3 apologized to R68, that they did not go through the medication list and care plan review include updating her care plan for Personalized Care during the last quarterly care conference on 01/13/25. Unit Nurse 3 reviewed R68's personalized care plan and confirmed it had not been revised since it started on 08/05/22. She stated the care plan would be revised at least quarterly during the care conference to meet R68's needs. Unit Nurse 3 stated she would revise it to address R68's needs. NJAC 8:39-11.2(e)(f)

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two residents (Resident (R) 142 and R28) out of 34 sample residents had an accurately coded Minimum Data Set (MDS) assessment. This failure increased the risk of inappropriate care provision to R142 and R28. Findings include: 1. Review of R142's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with medical diagnoses that included unspecified dementia without behavioral or psychotic disturbance and depression. Review of R142's admission MDS, located under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/04/24 showed R142 was coded for having depression, dementia, and psychotic disorder (other than bipolar). During an interview on 03/06/25 at 9:55 AM regarding the psychotic disorder diagnosis, the MDS Coordinator (MDSC) stated, There was a psych follow progress note in [EMR] on 12/04/24 that did show an active diagnosis of anxiety treated with prn [as needed] Xanax, however, I must have mistaken 'disruptive mood dysregulation disorder' and coded psychosis in error. The MDSC confirmed R142 had no diagnosis of psychosis. The MDSC stated she used the RAI Manual (Resident Assessment Instrument) and not a policy regarding MDS accuracy. During an interview on 03/07/25 at 4:35 PM regarding MDS accuracy, the Director of Nursing (DON) stated an expectation that MDS coding would be reviewed for accuracy and would follow the RAI guidelines. Review of the October 2024 Resident Assessment Instrument (RAI) Manual stated on page I-1 stated: Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. On Page I-7 showed: Steps for Assessment There are two look-back periods for this section: o Diagnosis identification (Step 1) is a 60-day look-back period. -Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period . 1. Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days. -Diagnostic information, including past history obtained from family members and close contacts, must also be documented in the medical record by the physician to ensure validity and follow-up. 2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses. 2. Per R28's undated Admission Record, located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 05/05/21 with diagnoses which included Alzheimer's disease, Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves,) anxiety disorder, and depressive disorder. During an observation on 03/04/25 at 4:29 PM, R28 was sitting on his bed with a tab alarm hanging on his right side of the bedrail with a string pinned on his grey shirt on his right chest. On 03/06/25 at 9:05 AM and 03/07/25 8:50 AM, R28 was observed sitting on the bed again with the tab alarm pinned on his right chest. Review of R28's Care Plan Report, located in the residents' EMR under the Care Plan tab, included a care plan for The resident is Moderate risk for falls. The care plan included the intervention of Pad alarm in bed and chair. Initiated 05/11/21. Revised 07/18/22. R28's Care Plan Report included a care plan for actual falls, initiated 01/05/22, revised 02/18/25, documented R28's fall events with the alarms used and interventions as follows: - A fall on 06/10/21 at 12:40AM, the intervention was bed alarm bed at night, tab alarm to wheelchair. Initiated: 06/10/21. - A fall on 11/02/21 at 4:55 PM, the intervention was replacing the broken tab alarms. - A fall on 01/4/22 at 11:30 AM, the intervention was continuing the tab alarms. - A fall on 01/4/22 at 11:30 AM, the intervention was continuing the tab alarms. - A fall on 02/17/25 at 10:55 PM, the intervention was replacing the broken bed alarms. Initiated 02/18/25. Review of R28's medication Administration Report for order range 01/01/25 to 03/06/25, documented R28 was in use of tab alarms for bed and chair as follows: - TAB ALARM TO WHEEL CHAIR, check for functioning and placement q [every] shift for safety hx [history] falls. Start date 06/10/21. - CHANGE PAD ALARM BATTERY MONTHLY ON THE 15TH every day shift every 1 month(s) starting on the 15th for 1 day(s). Start date 08/15/22. - TAB ALARM TO BED - CHECK PLACEMENT AND FUNCTIONING every shift. Start date 02/20/25. Review of R28's annual MDS with an ARD of 05/07/24, quarterly MDS with an ARD of 08/06/24, and quarterly MDS with an ARD of 02/04/25, located under the MDS tab of the EMR, revealed staff documented R28 did not use a bed alarm or chair alarm. During an interview on 03/07/25 at 11:15 AM, the MDSC reviewed R28's records and stated she would correct the three wrong MDS assessments immediately. Review of the October 2024 RAI Manual, under Chapter three, section P: RESTRAINTS AND ALARM, documented the following: - An alarm is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected, and may include bed, chair and floor sensor pads, cords that clip to the resident's clothing, motion sensors, door alarms, or elopement/wandering devices. - Adverse consequences of alarm use include, but not limited to, fear, anxiety, or agitation related to the alarm sound; decreased mobility; sleep disturbances; and infringement on freedom of movement, dignity, and privacy. - When the use of an alarm was considered as an intervention in the resident's safety strategy, use must be based on the assessment of the resident and monitored for efficacy on an ongoing basis, including the assessment of unintended consequences of the alarm use and alternative interventions NJAC 8:39-33.2(d)

Based on observations, record reviews, and interviews, the facility failed to ensure one of one resident (Resident (R) 79) reviewed for pain out of 34 sampled residents was offered nonpharmacological interventions and documented and followed physician's order to administer pain medication. This failure placed the resident at risk of unmanaged pain and had the potential to negatively affect his quality of life. Findings include: The facility's Pain Management Policy and Procedure, reviewed 01/25/25 and outlined the procedures for assessing and managing pain. These assessments included evaluating pain intensity, location, and duration, as well as observing facial expressions, cries, and moans. Based on these assessments, appropriate care plans for pain management were developed. The pain interventions included the following: - Nursing treatments, for example, facilitating hygiene, initiating relaxation techniques. - Nursing observations, for example, correcting a resident's or family's misconceptions about pain and its treatment and teaching the concept of resident controlled analgesia when applicable. - Medication. The policy further instructed staff to document the details of the residents' pain in a progress note. This documentation included the following information: pain location, intensity, quality, frequency, duration, radiation, and any precipitating factors. Additionally, staff should note the treatments used to relieve the pain and assess their effectiveness. This included documenting the resident's response, such as whether the resident reported that the pain is relieved or controlled, appears relaxed, can rest or sleep appropriately, and is able to participate in activities. Per R79's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 01/17/24 with diagnoses which included peripheral vascular disease (condition of narrowed arteries reduce blood flow to the arms or legs) and stroke. Review of R78's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/25 and located in the resident's EMR under the MDS tab revealed the facility assessed R79 to have a Brief Interview for Mental Status (BIMS) score of 10 out 15 which indicated the resident was moderately cognitively impaired. The MDS also indicated the resident could follow instructions to answer questions, but needed cueing to recall words, had limited range of motion (ROM) upper and lower extremities on one side, did not walk, required substantial to maximal assistance (help does more than half of the effort) for roll left and right on bed, and dependent (helper does all the effort) on bed to chair transfer. R79 experienced moderate pain and did not receive non-medication interventions for pian. On 03/04/25 at 2:58 PM, R79 was sitting in a wheelchair and wearing bilateral green protection boots in his room. R79 expressed concerns regarding his pain. R79 reported experiencing chronic pain, often rating it between 8 and 9 out of 10 on his right heel after his pressure ulcer had healed. R79 stated that the nursing staff had only offered him pain medication as an intervention. R79 stated that he would be willing to try hot packing, leg circulation exercises, or ice packing if it would relief his pain. Review of R79's Care Plan Report, located in the residents' EMR under the Care Plan tab, included a care plan for I am in pain/risk for pain r/t [related to] Chronic Physical disability, wounds, initiated 01/25/24. The care plan included the interventions as follows: - Administer pain medication per physician orders. Initiated 01/25/24. - Encourage / assist to reposition frequently for comfort as needed. - Implement non-drug therapies such as but are not limited to, application of heat/cold, massage, physical therapy, stretching and strengthening exercises, ultrasound as tolerated and ordered to assist with pain and monitor for effectiveness. - Monitor side effects of pain medication (i.e. constipation, GI [gastrointestinal] upset, Nausea/vomiting.) - Report non-verbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing. R79's Care Plan Report included a care plan for The resident has Peripheral Vascular Disease (PVD), initiated 03/21/24, revised 04/22/24. The care plan included the interventions as follows: - Educate resident to use caution with heating pads, hot water bottles. - Elevate legs when sitting or sleeping. - Encourage resident to change position frequently, not sitting in one position for long periods of time. Review of R79's Medication Administration Record (MAR) report from 12/01/24 to 03/06/25 and located in the resident's EMR under the Orders tab revealed R79 received some pain medications; however, not all pain medications were administered according to the physician's orders: - Gabapentin Capsule 300 MG Give 1 capsule by mouth at bedtime for Neurotic Pain. Start date 03/29/24. - Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for [650mg] mild pain 1-3. Start date 01/17/24. a. December 2024, not given. b. January 2025, not given. c. February 2025, was given two times when pain level 3/10. d. March 1 to March 6, 2025, was given two times when pain level 3/10. - traMADol [opioid] HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for moderate pain 4-6. Start date 01/27/24. a. December 2024 not given. b. January 2025, was given eight times when the pain level was between 5/10 to 8/10. The Administration Report documented the staff did not follow physician's order administered Tramadol instead of Percocet on 01/05/25 at 8:55 AM, and 01/24/25 at 12:27AM when R79 had severe pain, pain level 8/10. c. February 2025, was given six times when the pain level was between 4/10 to 6/10. d. March 1 to March 6, 2025, was not given. - Percocet [opioid] Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for severe pain 7-10. Start date 04/04/24. a. December 2024, was given forty-three times when the pain level was between 5/10 to 9/10. The Administration Report documented that the staff did not follow physician's order administered Percocet instead of Tramadol on 12/16/24 at 05:50 AM and 12/18/24 at 08:08 PM when R79 had moderate pain, pain level of 5/10. b. January 2025, was given forty-seven times when the pain level was between 0/10 to 9/10. The Administration Report documented the staff did not follow physician's order: On 01/05/25 at 04:06 PM, administered Percocet when R79 had no pain (0/10) On 01/13/25 at 09:41 AM and 01/17/25 at 08:39 AM, administered Percocet instead of Tramadol when R79 had moderate pain, pain level 5/10. On 01/24/25 at 10:07 AM, Percocet instead of Tramadol when R79 had moderate pain, pain level 6/10. c. February 2025 gave twenty-three times for pain 7/10 to 9/10. d. March 1 to March 6, 2025, was not given. Review R79's record revealed, there was no documentation that what non-pharmacological interventions for pain were offered or refused and if the opioid medication's adverse side effects had been monitored. During an interview on 03/06/25 at 11:12 AM, Unit Nurse 3 reviewed R79's record and stated the nurses usually offered nonpharmacological interventions as per the care plan before administering pain medication to R79; however, it was not documented. Unit Nurse 3 stated the nonpharmacological interventions for pain should be documented what had been given or offered and refused. NJAC 8:39-27.1(a)

Based on observation, record review, interview, and facility policy review, the facility failed to ensure that residents were evaluated for the need and safety for use of bed rails prior to the installation/use of rails, documented alternatives to bed rails were attempted prior to the use of bed rails, failed to document reasons for failure of alternatives, and failed to advise residents and/or Resident Representatives (RR) of the risks and/or benefits of rail use with informed consent signed prior to the installation of bed rails for three of three residents (Resident (R) 28, R74, and R124) reviewed for bed rail use. This failure had the potential for the resident or the RR to be uninformed of the risks associated with bed rail use and could put the residents at risk for injury or entrapment. Findings include: 1. Review of R74's undated Admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he admitted on [DATE] with diagnoses including Parkinson's disease, anxiety, dementia, and muscle weakness. Review of R74's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/26/24, located under the MDS tab of the EMR, revealed he scored two out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. Per the MDS, R74 exhibited physical behavioral symptoms directed toward others and was dependent on staff for bed mobility or transfers. Review of R74's Care Plan, dated 08/12/24 and located under the Care Plan tab of the EMR revealed, I am at risk for falls because I am on a psychoactive medication, I am on pain medication, I am weak, I have cognitive deficits, I have impulsive behavior, I have poor safety awareness, I have unsteady gait. The approaches included, I need 1/4 siderail up [on each side] when in bed to help with in turning and repositioning myself in bed and it is for my own safety. During an observation on 03/04/25 at 11:56 AM in R74's room, R74 was lying in bed with 1/4 bed rails in the up position on each side of the bed, in the middle of the bed. In a concurrent interview with R74's family member (F1), she stated the bedrails were used to keep him from falling out of bed, especially when he had spasms or was agitated. F1 stated she had signed a consent form for use of the bedrails and felt they were beneficial to keep R74 from falling out of bed. During observations on 03/06/25 at 9:11 AM, 10:03 AM, 11:31 AM, and 2:27 PM in R74's room, R74 was lying in bed with 1/4 bedrails up on both sides of the bed in the middle. Review of R74's Informed Consent for Use of Bed Rails, dated 03/03/24 and located in the hard chart at the nurses' station, revealed F1 consented to the use of bedrails. However, specific risks versus benefits of use were not documented on the form, nor was the type of rail or frequency of use specified. Review of R74's EMR under the Orders tab revealed an active physician's order, dated 05/17/24, for 1/4 siderails on each side of the bed every shift. Review of R74's EMR under the Assessment and Miscellaneous tabs and the hard chart at the nurses' station revealed there was no assessment of R74's need for, and safety with, bedrails. During an interview on 03/07/25 at 10:55 AM, Unit Nurse 2 stated R74 was not safe in bed without the rails, as he used them to aid in positioning as well as for fall prevention during muscle spasms. Unit Nurse 2 stated she was able to find the consent form for use and the initial Care Plan including bed rail use; however, she was unable to find an assessment for the use of bedrails. Unit Nurse 2 stated an assessment should be completed of the resident's need for, and safety with, bed rails before implementation. During an interview on 03/07/25 at 10:58 AM, Licensed Practical Nurse (LPN) 5 stated R74 preferred the bed rails up for safety and added R74 would hold on tight to the bed rails when he had spasms due to Parkinson's disease. LPN5 stated R74 should have been assessed upon admission for use of bed rails but was unsure if the assessment was completed. During an interview on 03/07/25 at 4:51 PM, the Director of Nursing (DON) stated R74 had not been assessed for the use of bed rails and would be assessed right away. The DON stated the trigger to complete the assessment was not updated in the EMR software, so R74's assessment was missed. 2. Per R28's undated Admission Record, located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 05/05/21 with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions,) Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves,) anxiety disorder, and depressive disorder. Review of R28's quarterly MDS with an ARD of 02/04/25, located in the resident's EMR under the MDS tab, revealed the facility assessed that the resident did not exhibit mood or behavioral symptoms. R28 was cognitively impaired and received antipsychotic and antidepressant medication. On 03/04/25 at 4:29 PM, observed R28 was sitting on his bed with a upper side rail up on his right side and his bed was against the wall on his left side. On 03/06/25 at 9:05 AM, and 03/07/25 at 8:50 AM, R28 was observed sitting on bed again with a side rail up his right side of bed. Review of R28's Care Plan Report, located in the residents' EMR under the Care Plan tab, included a care plan for Resident is at high risk for skin breakdown incontinence, cognitive loss, decreased mobility. Initiated 05/06/21, revised 11/21/22, included intervention of Provide 1/4 side rails to assist with positioning and comfort. R28's Care Plan Report included a care plan for actual falls I fell on [DATE] @ 4:00 AM in my room from my bed, initiated 01/05/22, revised 02/18/25, documented the intervention of was given a mild rail. Start date 06/07/22. R28's medication Administration Report for order range 01/01/25 to 03/06/25, documented R28 was monitored for side rails use daily as follows: - Mid Side Rail every Shift. Start date 06/07/22. - MID SIDE RAILS X2 WHILE IN BED EVERY SHIFT. Start date 09/27/22. Review of R28's record revealed R28's did not have a device use assessment for the side rail use. There was no documentation that the risks and benefits education was provided to the legal representative and the consent were obtained. During an interview on 03/07/25 at 5:08 PM, the DON stated there was no consent for the siderail use. The DON stated the facility had changed from a diffident EMR software to the current one a while ago; she was not aware the new EMR software did not have a process to obtain consent and assessments for siderails use. The DON stated the device use assessment for siderails should be done upon admission, readmission, and quarterly. 3. Review of R124's Admission Record from the EMR Profile tab revealed a facility admitted [DATE] with medical diagnoses including dementia. Review of R124's annual and quarterly MDS with ARDs of 10/28/24 and 01/28/25 showed a BIMS score of 99, indicative of the inability to complete the scoring due to incomplete, nonsensical, or refusal to answer. Observation of R124's bed on 03/05/25 at 10:19 AM showed bilateral upper bed rails. The resident was not in bed at this time. Review of R124's EMR Assessments and Miscellaneous tabs did not show any documented evaluation for the need or safe use for bed rails. Review of R124's EMR Progress Notes did not reveal any documentation of bed rail evaluation or risk/benefit discussion with R124's RR. During an interview on 03/07/25 at 3:10 PM, LPN2 stated Whenever [R124] is in bed, she has the bed rails in place because she uses them for mobility and to get in and out of bed. She is able to do that independently. Also present, LPN4 stated, She [R124] rarely naps. The left side rail goes down [demonstrated by LPN2 to show it goes in the middle third of the mattress] but the right one stays up near her head. During an interview on 03/07/25 at 4:21 PM, the DON stated, The side rail evaluations are not done. During the switch [named former and current EMR systems] somehow the side rail evaluations aren't triggering. I believe the nurses are doing them, there is just no place to document it. Unable to find any consent form for [R124]. Review of the facility's policy titled, Use of Side Rails, dated 01/23/25, revealed: Policy: To Provide for the safe and appropriate utilization of side rails. Procedure 1. Side rail Evaluation template shall be completed for all Admissions, Re-admissions, and as needed. 2. Side Rail Evaluation template may be completed by a licensed nurse . 4. Appropriate type of side rail shall be indicated on the assessment form. 5. Informed consent shall be obtained from the resident/responsible party . 7. Re-evaluation for appropriateness of side rail shall be completed Quarterly 8. IDT shall determine if the use of side rail is considered a restraint. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure two residents (Resident (R) 51 and R306) of 36 residents observed in Initial Pool had medications unattended at the bedside only with an assessment for safety and the ability to self-administer medications. These failures placed both residents at risk for overdose, missed medication doses, or misappropriation of medication. Findings include: 1. Review of R36's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed she admitted on [DATE] with diagnoses including post-polio syndrome and hemiplegia affecting the left dominant side. Review or R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/25, located under the MDS tab of the EMR, revealed she scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. R36 did not exhibit mood or behavioral symptoms. During an observation on 03/04/25 at 3:54 PM in R36's room, R36 was lying in bed with an over-bed table over her lap. There was a tube of Cortisone 10 (hydrocortisone anti-itch cream) on the over-bed table. R36 stated her skin, especially her right arm, was itching so she started applying cortisone cream. R36 stated the staff did not apply the cream for her; she applied it herself. Review of R36's Orders tab of the EMR revealed a physician's order, dated 09/26/24, for diphenhydramine (antihistamine) tablets as needed for itching and a physician's order, dated 12/31/24, for hydroxyzine (antihistamine) tablets as needed for itching. There was no order for hydrocortisone cream, nor was there an order to indicate R36 could self-administer medications. Review of R36's EMR under the Assessments tab revealed there was no assessment of the resident's safety with medications unattended at her bedside or ability to self-administer medications. Review of R36's EMR under the Care Plan tab revealed there was no plan of care addressing medications kept at the resident's bedside or self-administration of medications. During an observation on 03/07/25 at 10:34 AM in R36's room, R36 was again lying in bed with the tube of Cortisone 10 cream on the over-bed table in front of her. During a concurrent observation and interview on 03/07/25 10:37 AM in R36's room, Unit Nurse 2 verified the Cortisone 10 cream was left in R36's room unattended and R36 did not have an order for the cream and should not be self-administering medication. R36 stated her husband had brought in the cream. Unit Nurse 2 stated the staff should have reported the cream in R36's room for follow up, but she was not aware R36 was using the cream. 2. Observation and interview on 03/04/25 at 2:48 PM in R306's room revealed two open lidocaine patches laying on her overbed table. R36 stated she would be having a shower soon so the patches would be put on after her shower. She said the nurse had brought them into her room approximately one-half hour prior. Since she was having a shower soon, she left them on her overbed table and said she would put them on after her shower. During an interview on 03/0425 at 4:15 PM, Licensed Practical Nurse (LPN) 1 revealed she did not think there was any problem with leaving the lidocaine patches with R306 LPN1 stated she was sure R306 was safe to have medications left with her. Review of R306's admitted found under the Clinical Census tab of the EMR revealed she had been admitted on [DATE]. Review of R306's diagnoses found under the Medical Diagnosis tab of the EMR revealed she had diagnoses that included generalized osteoarthritis, low back pain and other chronic pain. Review of R306's admission MDS with an ARD of 02/27/25, located under the MDS tab of the EMR, revealed she had BIMS score of 15 which indicated she was cognitively intact. Review of R306's physician orders found under the Orders tab of the EMR revealed she had a 02/24/25 order for Lidocaine External Patch 4 % Apply to neck topically one time a day for pain and remove per schedule. Apply Lidocaine Pain Relief Max St [strength] 4 % Patch. Apply to back topically one time a day for pain. There was no physician's order for the self-administration of those medications. Review of R306's 02/21/25 Care Plan, located under the Care Plan tab in the EMR, revealed there was no plan of care addressing medications kept at the resident's bedside or self-administration of medications. Review of R306's Assessments tab of the EMR revealed there was no assessment for the self-administration of medications. During an interview on 03/05/25 at 3:00 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed R306 did not have an order or assessment to self-administer medications. LPN1 should not have left the Lidocaine Patches on the overbed table while she waited for R306 to have her shower. LPN1 should have kept the patches in the medication cart until she was ready to apply them. Review of the facility policy titled, Medication Administration - Self Administration, dated 02/07/25, revealed, Before a resident may exercise the right to self-administer medications: The assigned nurse must assess the resident's' cognitive, physical, and visual ability to carry out this responsibility . The assigned nurse/team must determine who will be responsible (resident or nursing) for the following: a. Storage of medications. b. Documentation of the administration of medications. c. Location of the medications administration (e.g. resident's room, nurse's station, activity room, etc.). The resident's Physician must be notified and orders obtained for self-administered Medications. Storage of medication will be monitored by nursing to ensure that medication is located in designated area. NJAC 8:39-29.2(c)6(d)

Based on observation, interview, review of medical records and review of other facility documentation, it was determined that the facility had a multi-system failure resulting in an immediate jeopardy situation; when multiple nurses failed to follow professional standards of nursing clinical practice by disregarding physician's orders [REDACTED]. Part A. Forty nurses on two units disregarded physician ordered parameters for insulin administration for a period of seven months from February 2019 to [DATE] for four of six residents reviewed, Residents #39, #[AGE], #100, and #155. In addition, ten nurses on one unit disregarded physician ordered parameters for administration of blood pressure medication for a period of six months from [DATE] to [DATE] for one of six residents reviewed, Resident #71. The facility's failure to administer medications according to physician ordered insulin parameters, blood pressure parameters and clinical standards of nursing practice had the likelihood to affect all residents receiving medications with physician ordered parameters. On at [DATE] at 11:13 AM, the facility Administrator was notified that an Immediate Jeopardy situation (IJ) had been identified. The IJ removal plan was put into place and accepted on [DATE] at: 2:46 PM for Resident's #39, #[AGE], #100 and #155. The Administrator ensured that immediate nursing education was provided regarding insulin orders with parameters and administration of blood pressure medication with parameters. The survey team continued to monitor throughout the survey that the facility instituted the plan of correction submitted. Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, 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 task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. INSULIN ADMINISTRATION 1.) RESIDENT #39 According to the Admission Record (AR) Resident # 39 was admitted to the facility on [DATE] with the medical [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS), an assessment tool used to assess a resident's functional capabilities and identify health problems dated [DATE], documented that Resident #39 was cognitively intact and required extensive assistance with all aspects of activities of daily living (ADL's). The MDS also reflected that the resident had a [DIAGNOSES REDACTED]. The surveyor reviewed the Care Plan dated [DATE] with the focus of Diabetes. An intervention implemented in Resident #39's care plan was to administer medications according to the physician's orders [REDACTED]. The Physician order [REDACTED]. Accu-checks were ordered to be conducted 3 times a day before meals with extra insulin coverage to be administered according to a sliding scale of blood glucose measurements. Additional insulin, [MEDICATION NAME], was ordered to be administered with the dosage based on the following parameters: A blood glucose of : ,[DATE]=0 Units of insulin ,[DATE]=4 Units of insulin ,[DATE]=6 Units of insulin ,[DATE]=8 Units of insulin 351- 400= 10 Units of insulin If the blood sugar is greater than 401 the physician was to be notified. According to the Medication Administration Record (MAR) for the period of [DATE] to [DATE], Resident #39 was administered the medication insulin outside of the physician ordered parameters 12 times out of 90 opportunities by 8 nurses. (LPN #29, RN #5, LPN #30, LPN #8, LPN #28, LPN #31, LPN #2, LPN #38) On [DATE], [DATE], [DATE], [DATE], and [DATE] at 7:30 AM, there were nurses' signatures documented on the MAR that insulin was administered. There was no documentation of the dose or injection site on the MAR. (LPN #29, LPN #30, LPN #8) On ,[DATE], ,[DATE], ,[DATE], and [DATE] at 11:30 AM, there were nurses' signatures documented on the MAR that insulin was administered. There was no documentation of dose or injection site on the MAR. (LPN #30, LPN #8, LPN #28) On [DATE] at 5:00 PM, there were a nurse's signatures documented on the MAR that insulin was administered There was no documentation of dose or injection site on the MAR. (LPN #31) On [DATE] at 7:30 AM the nurse documented that Resident #39's blood sugar was 121 and 2 units of regular insulin was administered. At 11:30 AM, the blood sugar was documented on the MAR as 121 and 4 units of insulin was administered. According to the physician ordered sliding scale, Resident #39 should not have received any insulin. (RN #5) The surveyor revived the Consultant Pharmacist (CP) Evaluation (a hand-written resident specific pharmacy report located on the resident's chart) dated [DATE]. This Evaluation contained no documentation that there were concerns with insulin being was administered outside the physician ordered parameters. On [DATE] at 9:30 AM, the surveyor interviewed the Cedar Unit Licensed Practical Nurse Unit Manager (LPN/UM #1) who stated that when the nurses received an insulin order, it's a matter of putting the order in the computer correctly to include the dose of the insulin and administration site on the body as to where the insulin was injected. LPN/UM # 1 further stated that even if the nurse did not put the dose and site of insulin in the electronic MAR, the nurse could take the initiative to enter this information on the MAR. Some nurses are doing it and some nurses are not. LPN/UM #1 did confirm that the nurses should be documenting if they are holding insulin or giving the insulin according to the physician's orders [REDACTED]. On [DATE] at 12:53 PM, the surveyor interviewed Resident # 39 who stated that he/she has not had any concerns associated with high blood sugar or low blood sugar while in the facility. On [DATE] at 1:00 PM, the surveyor attempted to conduct a telephone interview with LPN #5. The LPN was unavailable. On [DATE] at 10:23 AM, the surveyor interviewed LPN #30 by telephone, who stated that when a resident is on a sliding scale with parameters for insulin administration related to the blood glucose levels, she checked the residents blood sugar by fingerstick and then documented the blood sugar on the MAR. She then would look at the physician orders [REDACTED]. If the blood sugar was in the range in which insulin was to be administered, she would then give the insulin and document the dose of insulin and the administration site. She also added, I really don't know what happened and why I documented that I administered insulin outside of the ordered sliding scale parameters, that must be a mistake. 2.) RESIDENT #[AGE] According to the administration record, Resident #[AGE] was admitted on [DATE], with medical [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], indicated that the resident had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL's), but ate independently. The surveyor reviewed the diabetes focus in Resident # [AGE]'s care plan. On [DATE] the facility initiated an intervention to administer medication according to the physician's orders [REDACTED].>The surveyor reviewed an untitled report for Resident # [AGE] which revealed an original physician's orders [REDACTED]. According to Resident #[AGE]'s individualized insulin sliding scale insulin was ordered to be administered with the dosage based on the following parameters. These parameters were listed on the Medication Administration Record (MAR). If blood sugar (BS) = administer ,[DATE] = 10 Units 301- 351 = 15 Units If greater than 351 call MD (medical doctor). The surveyor reviewed Resident # [AGE]'s Physicians Order Report which revealed a revised physician's orders [REDACTED]. If BS is between ,[DATE] = administer 2 Units ,[DATE] = administer 3 Units This [DATE] physician's orders [REDACTED]. If BS is between ,[DATE] = administer 3 Units Humalog ,[DATE] = administer 5 Units Humalog ,[DATE] = administer 7 Units Humalog 351- 400 = administer 9 Units Humalog The surveyor reviewed Resident # [AGE]'s Physicians order report which revealed a revised physician's orders [REDACTED]. If BS is between ,[DATE] = administer 3 Units ,[DATE] = 5 Units ,[DATE] = 7 Units 351- 400 = 9 Units The surveyor reviewed Resident # [AGE]'s Physicians order report which revealed a revised physician's orders [REDACTED]. If BS is between ,[DATE] = administer 2 Units ,[DATE] = administer 3 Units The surveyor reviewed the electronic MARs for the period [DATE] to [DATE], and noted the following: -[DATE] until [DATE] documented that the medication was administered outside the physician ordered parameters 1 time out of 24 opportunities by 1 nurse, as indicated on the MAR. (RN #26) In addition, on [DATE], medication was documented as not administered when medication should have been given according to physician parameters. (RN #39) -[DATE] until [DATE] documented that the medication was administered outside the physician ordered parameters 26 times out of 124 opportunities by 3 nurses, as indicated on the MAR. On [DATE] and [DATE], at 7:30 AM, there were nurse's signatures documented on the MAR that insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site. On [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site. (LPN #19, RN #21, and RN #24) -[DATE] until [DATE], revealed that the medication was administered outside the physician ordered parameters 24 times out of 120 opportunities by 9 nurses, as indicated on the MAR. On [DATE], at 7:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. (LPN #19, LPN #3, LPN #22, LPN #25, LPN #40, LPN #23, LPN #38, RN #21, and LPN #41) -[DATE] until [DATE], revealed that the medication was administered outside the physician ordered parameters 32 times out of 124 opportunities by 10 nurses, as indicated on the MAR. On [DATE], at 7:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], [DATE], [DATE], [DATE] and [DATE] at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. (LPN #3, LPN #19, LPN #12, RN #20, RN #15, LPN #23, LPN #1, LPN #6, LPN #41, and LPN #42) -[DATE] until [DATE], revealed that the medication was administered outside the physician ordered parameter 20 times out of 120 opportunities by 9 nurses, as indicated on the MAR. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. (LPN #3, LPN #11, LPN #12, LPN #25, LPN #13, RN #15, and LPN #41) -[DATE] until [DATE], revealed that the medication was administered outside the physician ordered parameter 26 times out of 120 opportunities by 11 nurses, as indicated on the MAR. On [DATE], [DATE] and [DATE] at 7:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], at 9:00 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. (LPN #25, LPN #2, RN #20, LPN #3, LPN #4, LPN #43, RN #5, LPN #44, RN #34, RN #24, and LPN #6) -[DATE] until [DATE], revealed that the medication was administered outside the physician ordered parameter 10 times out of [AGE] opportunities by 9 nurses, as indicated on the MAR. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On [DATE], at 9:00 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. ( LPN #16, LPN #3, LPN #17, LPN #8, RN #15, LPN #1, LPN #43, LPN #45, and LPN #18) The surveyor reviewed the Consultant Pharmacist Evaluations and noted there was no documentation of medication errors documented for the period [DATE] through [DATE] for Resident #[AGE]. 3.) RESIDENT #100 According to the admission record, Resident # 100 was readmitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], indicated that the resident had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL's), but ate with supervision. The surveyor reviewed the diabetes focus in Resident # 100's care plan. On [DATE] the facility initiated an intervention to administer medication according to the physician's orders [REDACTED].>The surveyor reviewed Resident # 100's Physicians order report which revealed an original physician's orders [REDACTED]. If blood sugar (BS) ,[DATE] = administer 2 Units ,[DATE] = administer 4 Units ,[DATE] = administer 6 Units 351- 400 = administer 8 Units If greater than 400 or below 70 call MD. The surveyor reviewed Resident #100's electronic MAR's for the period [DATE] until [DATE] and noted the following: -[DATE] until [DATE], revealed that the medication was administered outside the physician ordered parameter 2 times out of 6 opportunities by 2 nurses, as indicated on the MAR, for Resident #100. (LPN #18 and LPN #1) 4.) RESIDENT #155 According to the AR with an admission date of [DATE], Resident #155 was admitted to the facility with the medical [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], indicated that the resident was cognitively intact and required extensive assistance with activities of daily living (ADL's), and ate independently. The surveyor reviewed the diabetes focus in Resident #155's care plan. On [DATE] the facility initiated an intervention to administer insulin according to the physician's orders [REDACTED].>The surveyor reviewed Resident #155's Physicians Order Report which revealed an original physician's orders [REDACTED]. If blood sugar (BS) ,[DATE]= administer 10 Units If BS greater than 300 or below 70 call MD. The surveyor reviewed Resident #155's electronic MAR's for the period [DATE] to [DATE], and noted the following: -[DATE] until [DATE] documented that the medication was administered outside the physician ordered parameter 1 time out of 41 opportunities by 1 nurse, as indicated on the MAR. (RN #15) The surveyor reviewed Resident #155's Consultant Pharmacist Evaluation dated [DATE]. There were no indications of medication errors documented by the PC. INTERVIEWS OF STAFF On [DATE] at 12:30 PM, the surveyor interviewed LPN #3 who worked on [DATE] on the 7:00 AM to 3:00 PM shift. LPN #5 confirmed the initials on the [DATE] eMAR for Resident #[AGE]'s at 7:30 AM were hers and confirmed the medication [MEDICATION NAME] U-100 was signed as given. LPN #5 stated the electronic signature was signed in error. LPN stated the computer program permits a nurse to sign off a medication regardless of the physician ordered parameters. LPN #5 stated she may have signed multiple items together and signed them all at one time. She stated her normal process was to leave the outliers off, such as medications held, and sign them off individually. During a follow up interview on [DATE] at 10:36 AM, LPN #3 told the surveyor the computer program would not allow her to enter the dose or the site. The surveyor showed the LPN the printout of the MAR and asked why other nurses could enter in the dose and site? LPN #5 stated she only documented on what was flagged in the system. She also stated that each dose and site should be indicated as mandatory with a red flag and if there was no spot to enter the information, she should have informed the supervisor. LPN #5 stated other nurses probably entered the dose and site information in the comment section. On [DATE] at 10:28 AM, the surveyor attempted to contact LPN #19 by telephone but was unsuccessful. LPN #19 did not return the call or stop in to speak with the surveyor. On [DATE] at 10:52 AM, the surveyor interviewed LPN #8 who had worked on [DATE] on the 7:00 AM to 3:00 PM shift by telephone. The surveyor read the LPN the order and the blood sugar results. LPN #5 confirmed that [MEDICATION NAME] U-100 should have been held based on the physician ordered parameters. LPN #5 also confirmed if a medication was not given, it was necessary to click, Not administered, in the computer program. On [DATE] at 12:40 PM, LPN #5 was in the facility and reviewed the paper printout of the eMAR with the surveyor. After this review, LPN #5 told the surveyor if the medication was held, a nurse must manually unclick the box indicating a medication was not administered. LPN #8 also said they may have been sidetracked and forgot to unclick the box. On [DATE] at 11:40 AM, the surveyor interviewed LPN #14 who had worked on [DATE] on the 3:00 PM to 11:00 PM shift. LPN #14 confirmed the initials on the [DATE] eMAR for Resident #[AGE]'s at 9:00 PM were hers and confirmed the medication Humalog U-100 was signed as given and it should have been held. LPN #14 indicated when a medication was not administered, the clinical rationale for holding the medication should be documented in the computer system drop down box. LPN #14 stated it was possible she was orienting a new nurse who may have signed under her name. On [DATE] at 11:34 AM the RN UM #1 told the surveyor medication order parameters were manually entered by charge nurses or the supervisor into the computer system for the parameters to populate. The RN UM #1 further revealed if a parameter did not populate in the computer system correctly, the nurse must inform her so she can make the correction. The RN UM #1 stated it was the responsibility of the pharmacy consultant to review the eMAR and find errors. The RN UM #1 indicated she didn't do a chart check. On [DATE] at 09:44 AM, the surveyor interviewed the Pharmacy Consultant (PC) by telephone. The PC revealed the facility nurses received an in-service on medication parameters in July and additional education on parameters was further provided to the facility in the pharmacy's third quarter report, The Quarterly Connection. The PC told the surveyor if she found a medication documented as administered and it was outside of parameters, she would immediately bring it to the, nurses' attention as well as the UM or supervisor and the Director of Nursing (DON). The pharmacist revealed she did not identify medication being signed as administered outside of physician ordered parameters as a repetitive issue in this building. The PC indicated that the dose and administration site should be documented in the eMAR. The PC further stated there were too many steps in the computer system to identify a pattern of medications being administered outside of parameters. The pharmacist was unable to provide documentation of education regarding insulin education and blood glucose parameters or documentation demonstrating corrective actions provided to the nurses, UM/supervisor and DON when parameter related medication errors occurred. On [DATE] at 10:06 AM, the surveyor interviewed the attending physician (MD#1) for Resident #[AGE] and Resident # 155 by telephone. MD #1 indicated he was not made aware of any medication errors for Resident #[AGE] or Resident #155 but described both residents as clinically fine regarding the residents' blood sugar. On [DATE] at 10:20 AM, the surveyor interviewed Resident's #100's physician (MD #2) by telephone. MD #2 revealed she was not aware Resident #100 was given medications outside parameters but would assume it was given according to the standard coverage and Resident #100 would not have been given more than 2 units. MD #2 stated medications should have been given according to ordered parameters. MD #2 indicated Resident #100 should not have been affected and remarked the medication error was not a terrible mistake. MD #2 further stated it was good practice to write down the dose on the MAR when administering the medication. On [DATE] at 09:34 AM, the DON revealed that physicians and the consultant pharmacist were responsible for reviewing the insulin administration documentation. The DON revealed the consultant pharmacist comes to the facility monthly and should review the eMAR's back to their previous visit. During a follow up interview with the DON on [DATE] at 09:00 AM, the DON told the surveyor the nursing staff believed when they were signing off in the computer, they were documenting the task of taking the blood sugar was completed instead of medication was administered for blood sugars outside of parameters. The DON further revealed the facility reached out to the computer program vendor regarding the parameters. The DON stated the vendor stated the system could not be changed and informed the facility to instruct the nurses to enter the information uniformly. The surveyor reviewed the undated job description of the Unit Manager. One of the main duties included monitoring programming and completing all documentation as necessary for the unit. HYPOTENSIVE MEDICATION 1.) RESIDENT #71 According to the Admission Record (AR) Resident # 71 was admitted to the facility on [DATE], with the medical [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE] indicated that Resident #71 had moderate cognitive impairment and required extensive assistance with all aspects of activities of daily living (ADL's). The MDS also reflected that the resident had a [DIAGNOSES REDACTED]. The POR revealed that there was an original order dated [DATE], for the medication [MEDICATION NAME] (used to increase the blood pressure) 2.5 mg to give 1 tablet 3 times a day and to hold the medication for systolic blood pressure (SBP) above 130. The parameters for holding the [MEDICATION NAME] were listed on the MAR. The surveyor reviewed Resident #71's MAR's for the period of [DATE] to [DATE] and noted the following: - [DATE] to [DATE], the medication [MEDICATION NAME] was administered outside the physician ordered blood pressure (B/P) parameter 2 times out of 52 opportunities by 2 nurses, as indicated on the MAR. (LPN #11 and LPN #41) - [DATE] to [DATE], the medication [MEDICATION NAME] was administered outside the physician ordered B/P parameter 3 times out of 90 opportunities by 3 nurses, as indicated on the MAR. (LPN #32, LPN #22, and RN #21) - [DATE] to [DATE], the medication [MEDICATION NAME] was administered outside the physician ordered B/P parameter 5 times out of [AGE] opportunities by 2 nurses, as indicated on the MAR. (RN #33 and RN #34). - [DATE] to [DATE], the medication [MEDICATION NAME] was administered outside the physician ordered B/P parameter 6 times out of 90 opportunities by 2 nurses, as indicated on the MAR. (LPN #25 and RN #33). - [DATE] to [DATE], the medication [MEDICATION NAME] was administered outside the physician ordered B/P parameter 11 times out of [AGE] opportunities by 4 nurses, as indicated on the MAR. (RN #33, LPN #32, RN #35, RN #21.) - [DATE] to [DATE], the medication [MEDICATION NAME] was administered outside the physician ordered B/P parameter 8 time out of 58 opportunities by 2 nurses, as indicated on the MAR. (RN #33 and RN #24.) The surveyor reviewed the Consultant Pharmacist Evaluations dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. There was no documentation on the Pharmacist monthly evaluations that reflected that the medication [MEDICATION NAME] was being administered by nurses outside of the physician ordered B/P parameters. On [DATE] at 11:35 AM, the surveyor interviewed the Director of Nursing (DON) who reviewed Resident #71's MAR from [DATE] to [DATE] and confirmed that some of the nurses gave Resident #71 [MEDICATION NAME] outside of the physician ordered parameters. The DON stated that, The order clearly reads that the medication should be held if the SBP was over 130. I don't know how the nurses could read the order and hold it one day and then give it the next day when the order did not change. On [DATE] 12:24 PM, the surveyor interviewed the Consultant Pharmacist who stated that she comes in monthly to review residents' medications and when she finds concerns, she would write recommendations and give them to the DON and administrator. The PC revealed that she did not find the medication error that the nurses were giving Resident #71's [MEDICATION NAME] outside of the physician ordered parameters. The consultant Pharmacist also stated, There are two ways to review medication administration on the computer program and the one way that I look to see if the medications were given as ordered by the physician must give me a false indicator. I should have looked at it a different way and then I could have seen that there was an error. On [DATE] at 9:33 AM, the surveyor interviewed the DON who stated that there was not a facility protocol to review the residents MAR every day. The DON added the PC was responsible to come to the facility every month to review the MAR and physician orders. She also added that if there was a medication error the PC would notify the DON right away. On [DATE] at 1:53 PM, the surveyor interviewed the Primary Care Physician (PCP) who stated that Resident # 71 was prescribed the medication [MEDICATION NAME] for [MEDICAL CONDITION]. He further added that B/P parameters were ordered because if the medication [MEDICATION NAME] was given when the blood pressure was high, it could make the blood pressure go higher which may have a negative impact on the resident if the blood pressure went too high. He stated that he was not aware that the nurses were administering blood pressure medication out of the physician ordered parameters. On [DATE] at 2:21 PM, the surveyor interviewed the MDS Coordinator Licensed Practical Nurse (LPN #11) by telephone who stated that he administered medications occasionally, however he was familiar with Resident #71. The LPN stated that he knew that the medication [MEDICATION NAME] was for [MEDICAL CONDITION] and that when he administered medications to residents with ordered B/P parameters, he would take the blood pressure and document the results (TRUNCATED)

Based on interview and record review, it was determined that the facility failed to ensure that the Pharmacy Consultant (PC): a.) consistently reviewed resident's medical records for drug irregularities and b.) consistently report and identify the irregularities in accordance with the PC agreement, during a 10 month period (October 2018 to July 2019). The deficient practice was identified for 4 of 32 residents, (Resident #39, #71, #147 and #[AGE]) reviewed for drug regimen review. This resulted in an immediate jeopardy situation when the pharmacy consultant failed to identy and report the irregularies and multiple nurses continued administer medications out of physician ordered parameters that resulted in the likelihood of serious injury or harm to all residents. The deficient practice was evidenced by the following: On 8/23/19 at 11:13 PM, the facility's Administrator was notified that an Immediate Jeopardy (IJ) situation had been identified related to the failure to ensure drug irregularities were discovered and acted upon. Errors were made by nurses who; A. disregarded physician ordered parameters for the administration of insulin, a medication that regulates blood sugar, for the period of February 2019 to August 2019 (7 months) according to the physician ordered parameters B. disregarded physician ordered blood pressure (B/P) parameters for the administration of medications that regulate B/P for the period of March 2019 to May 2019, a 6 month period. C. disregarded physician ordered blood pressure (B/P) or heart rates (HR) parameters for 2 of 6 resident (Resident #147 and #[AGE]). On 8/23/19 at 4:34 PM, the IJ removal plan was accepted and the facility initiated a drug regimen review for all residents with B/P parameters and/or insulin coverage and any irregularities will be reported to the Director of Nursing (DON), Administrator and Medical Director. In addition, the facility initiated an immediate drug regimen review for any residents who was currently on a sliding scale order and B/P medication parameters. The survey team verified elements of the removal plan that addressed the immediate actions taken by the facility and continued to do so throughout the survey. A review of the Medication Administration Records (MAR) revealed errors wherein insulin was either administered or not administered outside the physician ordered insulin parameters for the following identified timelines: 1.) According to the Admission Record (AR) Resident #39 was admitted to the facility on [DATE] with the medical [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS), an assessment tool that assesses a resident's functional capabilities and identifies health problems dated 5/30/19, documented that Resident #39 was cognitively intact and required extensive assistance with all aspects of activities of daily living (ADL's). The MDS also reflected that the resident had a [DIAGNOSES REDACTED]. The Physician order [REDACTED]. Monitoring of blood sugars, Accuchecks, were ordered to be conducted three times a day before meals. There was an order for [REDACTED]. Blood sugar 151 - 200 administer 2 Units Blood sugar 201 - 250 administer 4 Units Blood sugar 251 - 300 administer 6 Units Blood sugar 301 - 350 administer 8 Units Blood sugar 451 - 400 administer 10 Units Blood sugar greater than 401 notify the physician On 7/4/19, 7/11/19, 7/14/19, 7/21/19, [DATE] at 7:30 AM, there were nurse's signatures documented on the MAR that insulin was administered. There was no documentation of the dose or site on the MAR. On 7/14/19, 7/16/19, 7/21/19, 7/29/19 at 11:30 AM, there were nurse's signatures documented on the MAR that insulin was administered. There was no documentation of the dose or site on the MAR. On 7/5/19 at 5:00 PM, there was a nurse's signatures documented on the MAR that insulin was administered. There was no documentation of the dose or site on the MAR. On 7/6/19 at 7:30 AM a nurse documented that Resident #39's blood sugar was 121 and 2 Units of regular insulin was administered. At 11:30 AM a nurse documented that Resident # 39's blood sugar was 121 and 4 Units of regular insulin was administered. According to the physician ordered sliding scale, Resident #39 should not have received any insulin. The surveyor reviewed the Consultant Pharmacist (CP) Evaluation, a hand-written resident specific pharmacy report located on the resident's chart. This evaluation documented the following: Resident #39 had no documentation from the CP that there were issues with the medication insulin being administered outside of the physician ordered parameters for the time frame of 6/15/19 to 8/20/19. 2.) According to the AR Resident # 71 was readmitted to the facility on [DATE] with the medical [DIAGNOSES REDACTED]. The quarterly MDS assessment tool dated 6/6/19 documented that Resident #71 had moderate cognitive impairment, required extensive assistance with all aspects of activities of daily living (ADL's), and had a [DIAGNOSES REDACTED]. The POR revealed that there was an original order dated 3/12/2019 for the medication [MEDICATION NAME] (increases the blood pressure) 2.5 mg to give 1 tablet 3 times a day and to hold the medication for systolic blood pressure (SBP) above 130. The surveyor reviewed the MAR's for the period 3/12/19 until 8/20/19 and noted the following: - 3/1/19 to 3/31/19, the medication [MEDICATION NAME] was administered outside the physician ordered blood pressure (B/P) parameter 2 times out of 52 opportunities by 2 nurses. - 4/1/19 to 4/30/19, the medication [MEDICATION NAME] was administered outside the physician ordered B/P parameter 3 times out of 90 opportunities by 3 nurses. - 5/1/19 to 5/31/19, the medication [MEDICATION NAME] was administered outside the physician ordered B/P parameter 5 times out of [AGE] opportunities by 2 nurses. - 6/1/19 to 6/30/16, the medication [MEDICATION NAME] was administered outside the physician ordered B/P parameter 6 times out of 90 opportunities by 2 nurses. - 7/1/19 to 7/31/19, the medication [MEDICATION NAME] was administered outside the physician ordered B/P parameter 11 times out of [AGE] opportunities by 4 nurses. - 8/1/19 to 8/20/19, the medication [MEDICATION NAME] was administered outside the physician ordered B/P parameter 8 time out of 58 opportunities by 2 nurses. According to the Consultant Pharmacist Evaluation forms dated 3/18/19, 4/15/19, 5/13/19, 6/17,19, 7/15/19 and 8/20/19 there was no documentation referencing that the medication [MEDICATION NAME] was being administered outside of the physician ordered B/P parameters. 3.) According to the AR, Resident #147 was admitted to the facility on [DATE] with the medical [DIAGNOSES REDACTED]. The Significant Change MDS dated [DATE] documented that Resident #147 had short-term and long-term memory deficits and required extensive assistance with ADL's. On 8/21/19 at 10:30 AM, the surveyor reviewed Resident # 147's POR which reflected an original order dated 10/25/18, for [MEDICATION NAME] (antihypertensive) 2.5 mg to administer one tablet daily and to hold the medication for SBP below 100 and Heart Rate (HR) below [AGE] for the [DIAGNOSES REDACTED]. The surveyor reviewed the MAR's for the period 10/26/18 to 8/20/19 and there were no documented B/P's or HR's documented for the use of the medication [MEDICATION NAME] as prescribed by the physician. The Consultant Pharmacist Evaluations dated 11/26/18, 12/21/18, 1/25/19, 2/25/19, 3/19/19, 4/11/19, 5/16/19, [DATE] and 7/12/19, did not contain documentation related to the omission of B/P's and HR's related to the use of [MEDICATION NAME], when the physician had ordered specific B/P and HR parameters for the use of the medication. On 8/20/19 12:24 PM, the surveyor interviewed the Pharmacy Consultant (CP) who stated that she comes in monthly to review residents' medications and when she finds concerns, she would write document any concerns or recommendations and give them to the DON and Administrator. The CP revealed that she did not find the problem of staff giving the residents blood pressure medication outside of the physician ordered parameters. The CP told the surveyor that There are two ways to review medication administration on the computer program and the one way that I look to see if the medications were given as ordered by the physician must give me a false indicator. I should have looked at it a different way. Then I could have seen that there was an error. The CP indicated that she only randomly reviewed dates of administration of medications and did not look at the entire month of medication administration. On 8/21/19 at 9:33 AM, the surveyor interviewed the DON who stated that there was not a facility protocol to do a daily review of each resident's MAR. The DON added the CP was responsible to come to the facility every month to review the MAR and physician orders. She also added that if there was a error the PC would notify the DON right away. On 8/23/19 at 9:43 AM, the surveyor interviewed the CP by telephone who stated that she discussed this issue at the quarterly Quality Assurance Performance Improvement (QAPI), but did not reveal a date. The CP stated inservices were provided to the nurses relating to the importance of adhering to physicians orders in regards to blood pressure medications and parameters because the CP had noted this issue in other facilities. In regards to insulin I have not identified a wide spread issue and I did not see that nurses were giving insulin out of the physician ordered parameters. The PC further stated that doses and sites of insulin injections should be documented and stated Of course they should. 4. According to the admission record, Resident #[AGE] was admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], documented that the resident had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL's), was able to eat independently, had a [DIAGNOSES REDACTED]. The surveyor reviewed an untitled report for Resident # [AGE] which documented an original physician's orders [REDACTED]. The dosage of insulin to be administered was based on the following parameters: If blood sugar (BS) = administer 251-300 = 10 Units 301- 351 = 15 Units If greater than 351 call MD (medical doctor). The surveyor reviewed Resident # [AGE]'s POR which documented a revised physician's orders [REDACTED]. The Humalog insulin was to be administered based on the following parameters as listed in the MAR: If blood sugar (BS) = administer 301-350 = 2 Units 351- 400 = 3 Units The surveyor reviewed Resident # [AGE]'s POR which revealed a revised physician's orders [REDACTED]. The dosage of Humalog to be administered was based on the following parameters as listed in the MAR: If blood sugar (BS) = administer 201-250 = 3 Units 251-300 = 5 Units 301-350 = 7 Units 351- 400 = 9 Units The surveyor reviewed Resident # [AGE]'s POR which documented a revised physician's orders [REDACTED]. The dosage to be administered was based on the following parameters: If blood sugar (BS) = administer 201-250 = 3 Units 251-300 = 5 Units 301-350 = 7 Units 351- 400 = 9 Units The surveyor reviewed Resident # [AGE]'s POR which documented a revised physician's orders [REDACTED]. The dosage to be administered was based on the following parameters: If blood sugar (BS) = administer 301-350 = 2 Units 351- 400 = 3 Units The surveyor reviewed the electronic MAR's for the time period of 2/1/19 until 8/21/19, and noted the following: - 2/1/19 until [DATE], the insulin was administered outside the physician ordered parameters 1 time out of 24 opportunities by 1 nurse. In addition, on 2/19/19, insulin was not administered when it should have been given per physician parameters. - 3/1/19 until 3/31/19, revealed that insulin was administered outside the physician ordered parameters 26 times out of 124 opportunities by 6 nurses. On 3/6/19 and 3/7/19, at 7:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 3/2/19, 3/3/19, 3/4/19, 3/5/19, 3/6/19, 3/7/19, 3/8/19, 3/9/19, 3/10/19, 3/11/19, 3/12/19, 3/13/19, 3/14/19, 3/18/19, 3/19/19, 3/22/19, 3/23/19, 3/24/19, 3/26/19, 3/27/19, [DATE], 3/29/19, 3/30/19 and 3/31/19 at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 3/4/19, 3/12/19, 3/16/19, 3/18/19, 3/22/19 and [DATE] at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. - 4/1/19 until 4/30/19, revealed that insulin was administered outside the physician ordered parameters 24 times out of 120 opportunities by 6 nurses. On 4/24/19, at 7:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 4/1/19, 4/5/19, 4/7/19, 4/14/19, 4/16/19, 4/17/19, 4/18/19, 4/19/19 and 4/24/19 at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 4/5/19, 4/6/19, 4/12/19, 4/15/19, 4/28/19 and 4/29/19 at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. - 5/1/19 until 5/31/19, revealed that insulin was administered outside the physician ordered parameters 32 times out of 124 opportunities by 8 nurses. On 5/16/19, at 7:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 5/1/19, 5/2/19, 5/4/19, 5/5/19, 5/6/19, 5/9/19, 5/11/19, 5/12/19, 5/15/19, 5/16/19, 5/20/19, 5/22/19, 5/23/19, 5/24/19, 5/26/19, 5/28/19 and 5/30/19 at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 5/5/19, 5/7/19, 5/8/19, 5/19/19 and 5/27/19 at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. - 6/1/19 until 6/30/19, revealed that insulin was administered outside the physician ordered parameter 20 times out of 120 opportunities by 6 nurses. On 6/1/19, 6/2/19, 6/3/19, 6/6/19, 6/11/19, 6/12/19, 6/14/19, 6/16/19, 6/17/19, 6/25/19, 6/26/19, 6/27/19, 6/28/19, 6/29/19 and 6/30/19 at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 6/1/19, 6/2/19, 6/7/19, 6/15/19, 6/21/19, 6/29/19 and 6/30/19 at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. - 7/1/19 until 7/31/19, revealed that insulin was administered outside the physician ordered parameter 26 times out of 120 opportunities by 11 nurses. On 7/5/19, 7/6/19 and 7/9/19 at 7:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 7/1/19, 7/3/19, 7/6/19, 7/7/19, 7/9/19, 7/10/19, 7/11/19, 7/14/19, 7/15/19, 7/16/19, 7/17/19, 7/20/19, 7/21/19, 7/22/19, [DATE], 7/24/19, 7/35/19, 7/26/19, 7/27/19, 7/30/19 and 7/31/19 at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 7/2/19, 7/9/19, 7/11/19, 7/14/19, 7/16/19, 7/19/19 and 7/26/19 at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 7/16/19, at 9:00 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. - 8/1/19 until 8/21/19, revealed that insulin was administered outside the physician ordered parameter 10 times out of [AGE] opportunities by 6 nurses. On 8/1/19, 8/2/19, 8/3/19, 8/5/19, 8/6/19, 8/7/19, 8/8/19, 8/9/19, 8/10/19, 8/11/19, 8/12/19, 8/14/19, 8/16/19, 8/17/19, 8/19/19, and 8/20/19 at 11:30 AM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 8/2/19, 8/5/19, 8/6/19, 8/9/19, 8/19/19 and 8/20/19 at 4:30 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. On 8/10/19, at 9:00 PM, there were nurse's signatures documented on the MAR that indicated insulin was administered however, there was no documentation of dose or site on the MAR. A review of the CPE revealed there were no documention by the CP that insulin was being administered on numerous occasions during the period 2/1/19 through 8/8/19 for Resident #[AGE]. The facility Pharmacy Agreement dated 10/29/2019 reflected that the CP would be responsible for: - Monthly onsite review of drug regimen of each resident on the facility census and would report any irregularities to the nurses in charge and/or the attending physician and the Administrator. - Written reports as needed to the Quality Assurance and Pharmacy and Therapeutics Committees on the status of the facilities pharmaceutical services and staff performance. NJAC 8:39 - 29.2 (d), 29.3 (a)