Every finding on record at Inglemoor Rehabilitation and Care Center

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 2 of 23 residents (Residents #14, #39) call bells were within reach and able to use to accommodate the residents' needs. This deficient practice was evidenced by the following: 1. On 6/16/25 at 10:20 AM, While conducting the initial tour of the facility, the surveyor observed Resident #39 in their room, sleeping in bed, with the call bell hanging, on the floor, and not within the reach if of the resident. The surveyor reviewed the electronic medical record (eMR) of Resident #39, and revealed the following: A review of the admission Record (AR; an admission summary) that reflected that the resident had diagnoses of but not limited heart failure (inability of the heart to pump blood effectively) and kidney failure (inability of the kidneys to function effectively). A review of Resident #39's quarterly minimum data set (qMDS), an assessment tool, with an assessment reference date (ARD) of 6/8/25, reflected that the resident had a brief interview for mental status (BIMS) score of 10 out of 15, which indicated the resident had moderate cognitive impairment. A review of the Comprehensive Care Plan (CCP) revealed a focus that the resident was at risk for falls and an intervention that the resident's call light was within reach. 2. On 6/16/25 at 11:12 AM, the surveyor, while interviewing Resident #14 in their room, the surveyor observed the call bell on top of a dresser, behind several other items, and not within reach of the resident. The surveyor asked Resident #14 if they used the call bell if they needed help. The resident stated that they usually yell for help, and they did not know where the call bell was right now. On 6/18/25 at 12:17 PM, the survey team met with the Director of Nursing (DON). The surveyor asked the DON where the resident call bell should be in relation to the resident. The DON stated that the call bell should be within reach of resident and the resident should be able to access it. The DON also stated that call bell should not be on the floor. The surveyor notified the DON of the surveyor's observations of the call bell on the dresser and on the floor. The DON stated that the call bell should not be positioned that way. The surveyor reviewed the eMR of Resident #14, and revealed the following: A review of the AR, reflected that the resident had diagnoses of but not limited to; multiple fractures of ribs (broken ribs), unspecified fall, and need for assistance with personal care. A review of Resident #14's qMDS, with an ARD of 4/27/25, reflected that the resident had a BIMS score of 12 out of 15, which indicated the resident had moderate cognitive impairment. A review of the CCP, revealed a focus that the resident was at risk for falls and an intervention that the resident's call light was within reach. On 6/19/25 at 10:01 AM, the survey team met with the DON. The DON stated that the call bell concerns must have been a one-off incident and that all call bells were usually properly placed. The DON provided the surveyor a Call Bell policy. On 6/19/25 at 11:38 AM the surveyor interviewed the Charge Nurse (CN) on the unit where Residents #14 and #39 reside. The CN stated that all call bell should always be kept within reach of the resident based on their needs and capability. A review of the facility's Call Bells Policy, dated August 2021, reflected that residents shall be educated on admission and as needed, by staff on how to use the call bell system to request assistance. Further review of the above policy, revealed, the policy did not reflect any documentation on placement of call bells in relation to the resident. NJAC 8:39-29.2(d)

Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notice for 1 of 2 residents reviewed for Beneficiary Protection Notification, (Resident #141). This deficient practice was evidenced by the following: On 6/23/25 at 8:49 AM, the surveyor reviewed the Skilled Nursing Facility (SNF) Beneficiary Protection Notification (SNFBPN) Review completed by the facility for Resident #141 as followed: -The SNFBPN Review indicated Resident #141 last covered Medicare A day was 2/21/25, and Resident #141 remained in the facility. The SNFBPN Review further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) form was not given to Resident #141. A review of the electronic medical records (eMR) revealed that there was no documented evidence that the SNFABN was done nor the reason why it was not done. During an interview with the surveyor on 6/23/2025 at 9:09 AM, the Director of Social Services (DSS) was asked what SNFBPN were provided to a resident who is discharged (d/c) home, and the DSS replied We give them a NOMNC (Notice of Medicare non-coverage) form. The surveyor then questioned what forms were required to be provided to a resident who the facility-initiated d/c from Medicare A services and remained in the facility. The DSS replied that the Social Worker will give residents the SNFABN and NOMNC forms because residents were staying in house. At that same time, the surveyor notified the DSS of the above findings that Resident #141 was not provided the SNFABN form. The DSS stated that it was the other Social Worker (SW) who did the SNFBPN of the resident and it was probably in the miscellaneous (misc) tab of the eMR because usually they upload it in the eMR. The surveyor also notified the DSS that there was no documented evidence in the eMR that the SNFABN was uploaded. The DSS confirmed that the SNFABN should have been done and that she would get back to the surveyor as to why it was not done. On 6/23/25 at 9:26 AM, the surveyor interviewed the SW who was responsible for completing the SNFABN of Resident #141. The SW confirmed Resident #141 who stayed in facility after being cut from Medicare A should have received SNFABN and NOMNC. She further stated that they (social workers) issue them few days before the last covered day to give the resident or resident representative an opportunity to appeal. At that same time, both the surveyor and the SW reviewed the paper medical records of the resident. The SW confirmed that the SNFABN was not done and there was no documented evidence in the paper medical records a copy of the SNFABN. The SW stated, maybe it was an oversight. She further stated that SNFABN was being given if the resident wanted to appeal and they wanted to stay while waiting for the decision, and for Resident #141, the resident's appeal was not approved. On 6/23/25 at 10:17 AM, the survey team met with the Director of Nursing (DON). The surveyor notified the DON of the above findings and concern with Resident#141's SNFABN. The DON confirmed that the resident should have a SNFABN done. The DON stated that the facility did not have a policy about SNFABN, and the facility just follow the CMS (Centers for Medicare and Medicaid Services) guidance on SNFABNs. On 6/23/25 at 11:13 AM, the survey team met with the DON, Director of Dietary, Medical Director, and Infection Preventionist Nurse for an Exit Conference, and there was no additional information provided by the DON. NJAC 8:39-4.1(a)(8); 5.1

Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire for 1 of 6 newly hired licensed staff reviewed, Staff Member #1, in accordance to facility's policy. The deficient practice was evidenced by the following: On 6/17/25 at 9:40 AM, the surveyor requested ten randomly selected newly hired employee files from the Director of Nursing (DON). On 6/17/25 at 1:18 PM, after a brief review of the facility provided files which did not contain any documented license verification, the surveyor asked the DON to provide the surveyor the initial license verification documentation for each of the newly hired employees. A review of the facility provided documented license verification for six of the new licensed employees revealed the following: -Review of Staff Member #1 (SM#1), a Certified Nursing Assistant (CNA#1), hired on 12/10/23, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which was dated 2/18/25. There was no documented evidence that SM#1's license was verified prior to the date of hire (doh). On 6/18/25 at 9:36 AM, the surveyor interviewed the DON regarding the process for license verification. The DON stated that for new hires, the license verification was performed prior to doh by the Staffing Coordinator (SC), Human Resources Director or herself. The surveyor showed the DON SM#1s license verification that was dated 2/18/25. On 6/18/25 at 10:43 AM, the DON stated that the SC probably disposed of the initial license verification sheet when she got a new one. She added that she kept the verifications separately for renewal. On 6/18/25 at 12:12 PM, the surveyor notified the DON the concern that SM#1 did not have documented evidence that their license was verified prior to doh. On 6/19/25 at 10:07 AM, the DON stated that SM#1 had a license verification but that it was discarded when the annual check was done. She added that moving forward the initial check would be kept in their file and that the policy was updated. A review of the facility's New Hire Policy with a revised date of January 2013, included the following: Policy: All prospective employees of [facility name] must meet state and federal employment requirements and complete all pre-employment screening and documentation prior to beginning work 2. Credentials and Licensure (if applicable): Valid NJ licensure or certification must be presented and verified for all licensed or certified positions (e.g., Registered Nurse, Licensed Practical Nurse, CNA, and Administrator) . A review of the facility's Abuse and Neglect Policy with a revised date of 10/21/24, included the following: 2. Prevention and Education b. Licensed personnel are also screened by their respective licensing board/agency. i. Certified Nursing Assistants (CNAs) are screened through NJDOH State Registry . N.J.A.C. 8:39-43.15

Based on interview and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 1 of 23 residents (Resident #75) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: A review of the Centers for Medicare & Medicaid Services (CMS's) Resident Assessment Instrument (RAI; helps facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Version 3.0 Manual, October 2024, reflected in SECTION I: ACTIVE DIAGNOSES . 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 . Check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available. Coding Instructions-Code diseases that have a documented diagnosis in the last 60 days and 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 during the 7-day look-back period . On 6/16/25 at 10:41 AM, the surveyor observed Resident #75 lying on bed. The surveyor reviewed the medical records of Resident #75, and revealed: A review of the admission Record (an admission summary) documented that Resident #75 was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, heart failure, type 2 diabetes mellitus without complications, and chronic kidney disease stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of blood) unspecified. A review of Resident #75's modified comprehensive MDS (cMDS), with an Assessment Reference Date (ARD; the last day of the observation period) of 3/1/24, reflected under Section I, included but not limited to Non-Alzheimer's Dementia, heart failure, diabetes mellitus, and renal insufficiency, renal failure, ESRD (end stage renal failure). Further review of resident's most recent cMDS, with an ARD of 3/3/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severe cognitive impairment. Section I, included but not limited to Non-Alzheimer's Dementia, heart failure, diabetes mellitus, renal insufficiency, renal failure, ESRD, depression, and psychotic disorder. A review of the active personalized care plan (CP) revealed that the resident had a focus CP that included but not limited for the following: -use of antidepressant medication (med) related to (r/t) depression and insomnia that was initiated on 2/23/24. -use of antipsychotic med r/t paranoia and irrational fears that was initiated on 2/23/24. -had a behavior problem r/t behavior: suspicious ., pacing back and forth, exit seeking, and wanting to go home ., that was initiated on 2/26/24. -had diabetes mellitus that was initiated on 2/23/24. -had depression r/t dementia with hallucination that was initiated on 3/4/24. A review of February and March 2024 Order Summary Report (OSR) revealed a physician order (PO) that included but not limited to the following: -A PO for trazodone HCL (hydrocholoride) oral tablet (tab) 100 milligram (mg), give 1 tab by mouth at bedtime (HS) for depression/insomnia, with an order date of 2/23/24. -A PO for risperidone oral tab 0.25 mg, give 1 tab by mouth every 12 hours (hrs) for psychosis, with an order date of 2/23/24. A review of the electronic Medication Administration Record (eMAR) for February and March 2024, revealed that the above PO for trazodone and risperidone were signed daily by the nurses as medications (meds) were administered. A review of the Psychiatric Evaluation dated 2/27/24, revealed, Resident #75 was seen by the Physician Assistant (Psychiatrist) with psychiatric diagnosis of dementia, depression, anxiety, insomnia, and psychosis, and to continue with treatment plan. The Psychiatric Evaluation notes also reflected that the meds were reviewed which included trazodone 100 mg once a day for depression and risperidone 0.25 mg every 12 hrs for psychosis. On 6/17/25 at 11:00 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC). The RN/MDSC informed the surveyor the standard of practice in answering Section I of the MDS, we review hospital records, doctor's notes, and other physicians' consult notes. The surveyor asked if the facility follow the RAI manual for answering MDS or they have a separated policy for MDS, and she stated that they did not have a separate policy for MDS, and they do follow the RAI Manual. The surveyor notified the RN/MDSC of the above concerns that the resident's modified cMDS on 3/1/24, Section I did not include diagnosis for depression and psychosis, when the resident received trazodone and risperidone, and the Psychiatric Evaluation on 2/27/24, reflected diagnosis for depression and psychosis. On that same date and time, the RN/MDSC stated that psychiatric documentation of depression and psychosis diagnosis should have been reflected in the 3/1/24 MDS as the resident received psychoactive meds trazodone and risperidone during the lookback period and the documentation of diagnosis of the psychiatrist. The RN/MDSC also stated that the MDS should reflect an accurate information in the active diagnosis, and further stated that she would get back to the surveyor, and check all MDS. On 6/17/25 at 12:06 PM, the RN/MDSC informed the surveyor that she reviewed the MDS of Resident #75, and confirmed that the modified cMDS with an ARD of 3/1/24, was inaccurate, and should have been coded for depression and psychosis. She further stated that the MDS will be modified to reflect the accurate active diagnosis. On 6/18/25 at 12:06 PM, the survey team met with the Director of Nursing (DON), and the surveyor notified the DON of the above findings and concerns with MDS accuracy. On 6/23/25 at 11:13 AM, the survey team met with the DON, Directory of Dietary, Medical Director, and Infection Preventionist Nurse for an exit conference, there was no additional information provided by the DON. NJAC 8:39-33.2(a)(d)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to develop a baseline care plan for a newly admitted resident who received a psychotropic medication (med), specifically an antipsychotic med for 1 of 5 residents reviewed for unnecessary medications (Resident #191). This deficient practice was evidenced by the following: A review of Resident #191's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and hypertension (high blood pressure). A review of Resident #191's Physician Order Summary Report included the following orders: Aripiprazole (an antipsychotic used to treat schizophrenia, bipolar disorder, depression, and Tourette syndrome) 2 mg (milligrams), give 0.5 tablet (tab) by mouth at bedtime (HS) for bipolar disorder. Give with 1 tab=2 mg for total dose of 3 mg. Aripiprazole 2 mg give 1 tab by mouth at HS for bipolar disorder, give with 0.5 tab=1 mg for total dose of 3 mg. On 6/17/25 at 9:25 AM, the surveyor reviewed Resident #191's care plan (CP) which was initiated on 6/12/25. The baseline CP did not include a plan of care related to receiving an antipsychotic (previously known as neuroleptics and major tranquilizers, are a class of psychotropic med primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders) med. A review of Resident #191's electronic medical record indicated the admission minimum data set (MDS), an assessment tool used to facilitate the management of care, was still in progress. On 6/17/25 at 11:12 AM, the surveyor interviewed the Horizon East Charge Nurse (HECN) regarding Resident #191's CP, and the HECN stated that the MDS Coordinator (MDSC) and nurse had a week for an antipsychotic med CP but it should be the first day or two. The HECN stated that for Resident #191, the MDSC wanted to wait to clarify the behaviors until the Psychiatrist came. The HECN further stated that the Resident's Responsible Party (RRP) did not want the facility's Psychiatrist, and that the resident's regular Psychiatrist had a scheduled visit. On 6/17/25 at 11:25 AM, the surveyor interviewed the MDSC, who stated that she reviewed Resident #191's orders and saw the med Abilify (Aripiprazole) which could be an antipsychotic or antidepressant. She added that she was going to wait until she did a CP for antipsychotic. The MDSC stated that she was going to wait to see the behavior and what kind of diagnosis, whether it was psychosis or paranoia. She added that she was waiting for the Psychiatrist to come yesterday but that the RRP wanted their own Psychiatrist. The MDSC stated that she was waiting for the verification of the actual indication and follow up with Psychiatrist and check if for bipolar. She added that she had within seven days to create a CP. The surveyor asked if the resident was seen by the Psychiatrist. The MDSC stated that she still had to verify and that she would call the Psychiatrist. On 6/18/25 at 9:50 AM, the surveyor interviewed the Director of Nursing (DON) regarding CP for antipsychotic med. The DON stated that when a resident was started on an antipsychotic med or any psychotropic (drugs that affect the brain's activity and are used to treat mental illnesses like depression, anxiety, and psychosis that work by altering the levels of chemicals in the brain that influence mood, behavior, and perception) med that they tried to involve the multidisciplinary team to develop a comprehensive CP which involved the Physician and Psychiatrist. She added that they implemented a plan of care for the med. The DON stated that the CP was comprehensive and had seven days to develop from admission or significant change. The surveyor asked the DON if an antipsychotic med should be on a baseline care plan. The DON stated that if they had behavior and on a antipsychotic should be on a baseline. She added that the RRP refused the facility's Psychiatrist. On 6/18/25 at 12:12 PM, the surveyor notified the DON the concern that Resident #191 did not have a CP for antipsychotic med on their baseline CP within 48 hours. On 6/19/25 at 10:03 AM, the DON stated that the facility initiated behavior monitoring on admission and started a comprehensive CP. She added that they have seven days to develop a full comprehensive CP, and believed they were still working on it. A review of the facility's Psychotropic Medications Policy with a revised date of 6/6/23, included the following: Purpose: To establish a system for assuring proper use and monitoring of psychotropic medications (meds). Policy: 1. For the purpose of this policy, a psychotropic med is any drug prescribe with the goal to alter behavior, mood, thoughts and/or perceptions. a. Examples of subclasses of psychotropic meds include: antidepressants, antipsychotics . 2. Physician's orders are required for the use of all psychotropic meds. a. Psychotropic meds shall only be used as part of a plan to eliminate/reduce specific symptoms and/or to treat a specific diagnosis. 3. A Psychiatric consult is required for all residents using psychotropic meds. 4. Initiation of Treatment with Psychotropic Meds . c. An appropriate diagnosis shall appear in the resident's medical record for the psychotropic med, and the physician's order shall include the appropriate indication . 5. Monitoring Use of Psychotropic Meds a. Nurses shall monitor every shift for resident-specific target behavioral, mood, thought and/or perception issues, as well as adverse reactions to the psychotropic med, and document specific occurrences of these issues. c. The resident's plan of care shall include reasonable and measurable objectives related to the use of the psychotropic med and the resident's relevant diagnosis. A review of the facility's Interdisciplinary Care Plan (IDCP) Team: Baseline Care Planning Policy dated January 2018, included the following: Policy: It is the policy of this facility that all residents shall have individualized CPs that reflect their specific needs/preferences. Procedure: 1. Each profession (i.e. nursing, social services, dietary, activities, and therapy) is responsible for assessing [NAME] residents and initiating a comprehensive CP(s) as it relates to their discipline according to current regulatory guidelines. a. The CPs shall be initiated within 48 hours of admission and completed no later than 7 days after admission. b. Nursing shall perform a bedside assessment and initiate relevant CPs on the day of admission. c. Physician's orders shall be obtained upon admission. 2. The IDCP team shall meet with the resident and/or family within 48-72 hours of admission to discuss the current (baseline) plan of care, including but not limited to: a. Resident goals, including discharge b. Physician orders c. Dietary instructions d. Any services/treatments required 3. During the IDCP team meeting, the resident and/or family shall be given an opportunity to ask questions and provide clarification/feedback. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen, according to the standard of clinical practice specifically the posting of cautionary and safety signs indicating the use of oxygen were utilized for residents that received oxygen therapy for 1 of 1 residents reviewed for respiratory care (Resident #34). This deficient practice was evidenced by the following: Reference: National Institutes of Health defines oxygen (O2) as a colorless, odorless and tasteless gas. It will support life. It is noncombustible, but will actively support the burning of combustible materials. Some materials that will not burn in air will burn in O2. Materials that burn in air will burn more vigorously in O2. On 6/17/25 at 10:06 AM, the surveyor observed Resident #34 lying in bed and received O2 via a nasal cannula (n/c) tubing at 3 LPM (liters per minute) that was connected to an O2 concentrator. The surveyor observed that Resident #34's entrance to their room did not have an O2 in use sign. A review of Resident #34's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; acute and chronic respiratory failure (the inability of the lungs to adequately oxygenate the blood or remove carbon dioxide), chronic obstructive pulmonary disease ( COPD, is a progressive lung disease that makes it hard to breathe), and congestive heart failure (a condition where the heart cannot pump enough blood to meet the body's needs). A review of Resident #34's comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 5/28/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #34 was cognitively intact. Further review indicated that the resident received O2 therapy. A review of Resident #34's Order Summary Report which included a physician's order for O2 at 3 LPM via n/c continuously. On 6/17/25 at 11:32 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding O2, and Resident #34. The LPN stated that Resident #34 received O2 therapy. On 6/17/25 at 11:35 AM, the surveyor asked the LPN to observe Resident #34's entrance to their room. The LPN confirmed there was no cautionary sign at the entrance of Resident #34's room. The LPN after checking with the Charge Nurse stated that the facility was smoke free and that there was not a need for the O2 in use signs on the door. On 6/17/25 at 11:38 AM, the surveyor interviewed the Horizon East Charge Nurse who stated that the facility did not use O2 in use signs since the facility was a non smoking facility and using signs was not in the policy. On 6/18/25 at 9:55 AM, the surveyor interviewed the Director of Nursing (DON) regarding O2 and cautionary signage. The DON stated that the facility did not use O2 in use signs. On 6/18/25 at 12:12 PM, the surveyor notified the DON the concern that Resident #34 did not have a cautionary sign posted for O2 in use. On 6/19/25 at 10:06 AM, the DON stated that the facility was smoke free and that the residents were made aware on admission. She added that she updated the policy and placed O2 in use signs at the doorway of the resident's room that received O2. The DON did not provide any additional information. A review of the facility's Oxygen Therapy Policy, Oxygen Concentrator (Care and Use), and Liquid Oxygen Usage Protocol all with a revised date of 10/24/24, did not have any information regarding cautionary signs for O2 use. A review of the facility's Smoke-Free Environment Policy with a reviewed date of February 2025, included the following: I. New admissions are informed prior to admission that we are a smoke-free facility. The policy did not have any information regarding O2 use or signage. N.J.A.C. 8:39-27.1(a)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate and appropriate administration of a medication (med) for 1 of 6 residents observed during the facility's med pass observation. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/17/25 at 9:15 AM, the surveyor, while observing the med pass (med-pass), observed the Licensed Practical Nurse (LPN) prepare and administer medications (meds) for Resident #74. The surveyor observed the LPN prepare the med aspirin EC (enteric coated) low dose oral tablet (tab) delayed release 81 mg (milligram), (ASA EC 81), [a med used to reduce blood clotting that has a protective coating that slows dissolving to help prevent stomach upset], crushed the ASA EC 81, and administered it along with the resident's other due meds in applesauce. The surveyor asked the LPN if the resident always received their meds crushed. The LPN stated, yes, they were a thickened diet, so it gets crushed. At that same time, the surveyor asked the LPN to read the med order on the resident's electronic med administration record (eMAR). The LPN reviewed the order with the surveyor, the surveyor identified to the LPN the statement on the order do not crush. The surveyor asked the LPN if she should have crushed the med and what was the policy or procedure if there was a med that needs to be crushed but cannot be due to manufacturer specifications. The LPN stated that the resident needed it crushed and usually the doctor was called to change the order to something that can be crushed. The surveyor concluded the observation. The surveyor reviewed the electronic medical record (EMR) of Resident #74, which revealed the following: A review of the admission Record (an admission summary) which reflected that the resident had diagnoses that included but were not limited to hypertension (high blood pressure), and paroxysmal atrial fibrillation (periodic irregular heartbeat). A review of Resident #74's Comprehensive Care Plan (CCP), revealed a focus that the resident was on an aspirin regimen with a goal to be free from discomfort or side effects from it, as well as a focus that the resident has a deficiency in swallowing skills. A review of Resident #74's eMAR revealed an order for ASA EC 81 that was administered 6/17/25, with directions not to crush. The eMAR also reflected that the order for ASA EC 81 was discontinued (d/c), with an order for aspirin oral tab chewable 81 mg (ASA Chew 81) being initiated after the surveyor's inquiry. On 6/18/25 at 12:17 PM, the survey team met with the Director of Nursing (DON). The surveyor discussed the results of the med-pass observation with the DON and asked if ASA EC 81 should be crushed. The DON stated, no, it should not be crushed, the order should be changed if it needs to be. On 6/19/25 at 12:53 PM, The surveyor interviewed the facility Consultant Pharmacist (CP) by telephone and asked if it was appropriate to crush ASA EC 81. The CP stated no, it should not be crushed. On 6/23/25 at 10:17 AM, the survey team met with the DON, and the DON did not provide additional information. A review of the facility's Medication Pass Policy with a revised date of August 15, 2023, reflected, under Procedure: 1. All meds shall be administered by a nurse as per current physician orders, within the acceptable standards of practice. NJAC 8:39-29.2(d)

Based on interview and record review, it was determined that the facility failed to a.) ensure practitioners and providers documented appropriate indications for use of antipsychotic and antidepressant medications (meds) and b.) identified discrepancy between practitioners and providers documented diagnosis for use of antipsychotic medication in accordance with the professional standards of clinical practice and facility policy. This deficient practice was identified in 1 of 5 residents, Resident #75, reviewed for unnecessary meds. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. On 6/16/25 at 10:41 AM, the surveyor observed Resident #75 lying on bed. The surveyor reviewed the medical records of Resident #75, and revealed the following: A review of the admission Record (an admission summary) revealed that Resident #75 was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, heart failure, type 2 diabetes mellitus without complications, and chronic kidney disease stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of blood) unspecified. A review of Resident #75's modified comprehensive MDS (cMDS), with an Assessment Reference Date (ARD; the last day of the observation period) of 3/1/24, reflected under Section I: Active Diagnosis, included but not limited to Non-Alzheimer's dementia, heart failure, diabetes mellitus, and renal insufficiency, renal failure, ESRD (end stage renal disease). A review of the active personalized care plan (CP) revealed that the resident had a focus CP that included but not limited for the following: -use of antidepressant medication (med) related to (r/t) depression and insomnia that was initiated on 2/23/24. -use of antipsychotic med r/t paranoia and irrational fears that was initiated on 2/23/24. -had a behavior problem r/t behavior: suspicious ., pacing back and forth, exit seeking, and wanting to go home ., that was initiated on 2/26/24. -had depression r/t dementia with hallucination that was initiated on 3/4/24. A review of Order Summary Report (OSR) revealed a physician order (PO) that included but not limited to the following: -A PO for trazodone HCL (hydrocholoride) oral tablet (tab) 100 milligram (mg), give 1 tab by mouth at bedtime (HS) for depression/insomnia, with an order date of 2/23/24. -A PO for risperidone oral tab 0.25 mg, give 1 tab by mouth every 12 hours (hrs) for psychosis, with an order date of 2/23/24. A review of the electronic Medication Administration Record (eMAR) for February and March 2024, and June 2025, revealed that the above PO for trazodone and risperidone were signed daily by the nurses as administered. A review of the Physician's History & Physical (H & P) dated 2/23/24, that was electronically signed by the physician on 2/24/24, revealed under assessment and plan: CHF (congestive heart failure) exacerbation .diabetes mellitus .dementia-continue Risperdal (also known as risperidone) and trazodone . A review of the Interval Progress Note (PN) revealed the following: -effective dates: 2/26/24, 3/1/24, 3/4/24, 3/6/24, 3/25/24, 5/31/24, 7/19/24, 7/31/24, 8/12/24, 10/28/24, 12/18/24, 2/24/25, and 4/28/25, electronically signed by the physician, included an assessment and plan, not limited to diagnosis for dementia-continue Risperdal and trazodone. -effective dates: 2/29/24, 4/30/24, 6/28/24, 5/27/25, 9/26/24, 11/21/24, 1/28/25, 3/27/25, 5/27/25, electronically signed by the Nurse Practitioner (NP), included an assessment and plan, not limited to diagnosis for dementia-continue Risperdal and trazodone. A review of the Psychiatric Evaluation dated 2/27/24, revealed, Resident #75 was seen by the Physician Assistant (Psychiatrist), documented the resident's psychiatric diagnosis of dementia, depression, anxiety, insomnia, and psychosis, and to continue with treatment plan. The Psychiatric Evaluation notes also reflected that the meds were reviewed which included trazodone 100 mg once a day for depression and risperidone 0.25 mg every 12 hrs for psychosis. Further review of the above PN and Psychiatric Evaluation revealed that there was discrepancy on the indications for use of risperidone (antipsychotic) and trazodone (antidepressant) meds. The resident's physicians documented that Risperidone and trazodone were for diagnosis of dementia while the Psychiatrist documented resident's use of risperidone for psychosis and trazodone for depression. On 6/18/25 at 12:06 PM, the survey team met with the Director of Nursing (DON), and the surveyor notified the DON of the above findings and concerns that there was a discrepancy with indications of use for meds risperidone and trazodone versus the physician and the NP's documentation of diagnosis. On 6/19/25 at 10:01 AM, the survey team met with the DON. The DON stated that she spoke with the physician regarding her documentation with meds Risperdal and trazodone and the diagnosis of dementia and what the appropriate indications for use. The DON stated that according to the physician, the diagnosis should be dementia with behavioral disturbance for both Risperdal and trazodone. The surveyor then asked the DON why the diagnosis sheet in the AR did not reflect dementia with behavioral disturbance, and why the Psychiatrist did document depression and psychosis, and the DON did not respond. The DON showed the PN of the physician dated 6/18/25, which the DON confirmed that the PN that included diagnosis for dementia with behavioral disorder, depression and insomnia to continue Risperdal and trazodone, was documented after surveyor's inquiry. A review of the facility's Psychotropic Medications Policy, with a revised date of 4/13/18, that was provided by the DON, revealed, the purpose was to establish a system for assuring proper use and monitoring of psychotropic meds. Policy: 1. For the purpose of this policy, a psychotropic med is any drug prescribe with the goal to alter behavior, mood, thoughts and/or perceptions. a. Examples of subclasses of psychotropic meds include: antidepressants, antipsychotic's, sedative/hypnotics, mood stabilizers . 2. PO are required for the use of all psychotropic meds. a. Psychotropic meds shall only be used as part of a plan to eliminate/reduce specific symptoms and/or to treat specific diagnosis . 4. Initiation of treatment with psychotropic meds . d. An appropriate diagnosis shall appear in the resident's medical record for the psychotropic med, and the PO shall include the appropriate indication . A review of the facility's Physician Services & Documentation Policy, with a revised date of 6/6/23, that was provided by the DON, revealed, 1. This document the term physician applies to physicians, Physician's Assistants and NPs. 2. Resident information is made available to the facility, prior to or at the time of admission, and shall include pertinent medical findings, diagnoses, and orders from a physician for the immediate care of the resident . On 6/23/25 at 11:13 AM, the survey team met with the DON, Director of Dietary, Medical Director, and Infection Preventionist Nurse for an exit conference, there was no additional information provided by the DON. NJAC 8:39-33.2(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 5 medication carts (med carts) observed in the facility. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/18/25 at 10:53 AM, the surveyor began to inspect selected medication (med) storage areas in the facility. The surveyor observed the following: The surveyor in the presence of Licensed Practical Nurse (LPN) inspected the med cart identified as cart bottom cart located on Reflections unit. Upon opening the med cart, the surveyor observed the LPN remove a plastic med dose cup (med cup) which contained three unmarked tablets. The surveyor asked the LPN what they were removing from the cart. The LPN stated that it was med that was previously refused by a resident and that they were going to try again. The surveyor asked the LPN if med should be stored without a resident's name or what the med was. The LPN stated that they knew the resident and the medications (meds) were for blood pressure. The surveyor asked the LPN if someone else had to take over the med cart, how would they know who the meds were for and what they were. The LPN stated they would dispose of the meds. The surveyor asked the LPN what the policy was for residents who refuse meds. The LPN stated that the med was offered three separate times to the resident, the doctor was then notified if it was still refused, then the med was disposed of if not taken. The surveyor concluded the inspection of that med cart. On 6/18/25 at 12:17 PM, the survey team met with the Director of Nursing (DON). The surveyor asked the DON what the policy or procedure was for a resident that refuses meds. The DON stated that the med should be disposed of after the resident refused the first time, the refusal was documented and the Physician notified. The DON also stated that the med may be offered again with a one time order from the Physician and new med removed from the packaging. The DON further stated that no unlabeled meds should be kept in the med cart. On 6/19/25 at 10:01 AM, the survey team met with the DON, the DON stated that the LPN who saved the unlabeled meds was re-educated. On 6/19/25 at 12:53 PM, The surveyor interviewed the facility Consultant Pharmacist (CP) by telephone and discussed the med storage concerns. The CP stated that the meds should not be stored unlabeled in a cup in the med cart. On 6/23/25 at 10:17 AM, the survey team met with the DON, and the DON provided an education in-service sign in sheet for med refusal/destruction conducted by the CP, and stated that education will continue. A review of the facility's Receiving & Storage of Medications Policy with a revision date of December 4, 2024, the policy did not reflect anything about med refusal or disposal. A review of the facility's Medication Pass Policy with a revision date of August 15, 2023, reflected, under Procedure: 1. All meds shall be administered by a nurse as per current physician orders, within the acceptable standards of practice. NJAC 8:39-29.4 (a)1-10, (g)(h)

Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete and accurate medical records. This deficient practice was identified for 4 of the 23 residents reviewed (Residents #75, #79, #191, and #192). This deficient practice was evidenced by the following:1. During the initial tour of the Reflections unit on 6/16/25 at 10:30 AM, Surveyor #1 (S#1) observed Resident #79 seated in a wheelchair (w/c) and informed S#1 that they had multiple hospitalizations. S#1 reviewed the medical records of Resident #79, and revealed the following:A review of the admission Record (AR; an admission summary) revealed that Resident #79 was admitted to the facility with diagnoses that included but were not limited to; neurocognitive disorder with Lewy bodies (a type of dementia characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions), anxiety disorder unspecified, and unspecified psychosis not due to a substance or known physiological condition.A review of Resident #79's most recent comprehensive minimum data set (cMDS), with an assessment reference date of (ARD) of 5/4/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Section I: Active Diagnosis included but not limited to non-Alzheimer's dementia (example (e.g.) Lewy body dementia .), anxiety disorder, depression, and psychotic disorder.A review of the active personalized care plan (CP) revealed that the resident had a focus CP and interventions that included but not limited for the following:-use of antidepressant medication (med) related to (r/t) depression that was initiated on 4/22/25. Interventions included but not limited to, monitor/document side effects (s/e) and effectiveness. S/e: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations, that were initiated on 4/22/25.-use of anti-anxiety medications (meds) r/t anxiety disorder that was initiated on 4/23/25. Interventions included but not limited to monitor/document s/e and effectiveness. Interventions: monitor/record occurrence of for target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc) and document per facility protocol that was initiated on 4/23/25.-use of antipsychotic med r/t psychosis that was initiated on 4/23/25. Interventions included but not limited to identify potential s/e .-had a behavior problem r/t (hallucinations, paranoia and delusions, refusing meds and care) that was initiated on 6/3/25. Interventions included but not limited to monitor/document for s/e that was initiated on 6/3/25.A review of the Order Summary Report (OSR) revealed a physician order (PO) that included but not limited to the following:-A PO for abilify oral tablet (tab) 10 milligrams (mg), give 1 tab by mouth one time a day (OD) for psychosis, with an order date of 4/22/25, and discontinued (d/c) on 5/21/25.-A PO for aripiprazole tab 5 mg, give 1 tab by mouth OD for psychosis, with an order date of 5/21/25, and d/c on 6/18/25.-A PO for aripiprazole oral tab 2 mg, give 0.5 tab by mouth OD for psychosis for 10 days (0.5 tab=1 mg), with an order date of 6/18/25, and end date of 6/29/25.-A PO for buspirone HCL (hydrocholoride) oral tab 10 mg, give 1 tab by mouth three times a day (3x/day) for anxiety, with an order date of 4/25/25.-A PO for Mirtazapine oral tab 15 mg, give 1 tab by mouth at bedtime (HS) for depression, with an order date of 4/22/25.-A PO for sertraline HCL oral tab 100 mg, give 2 tablets (tabs) by mouth at HS for depression (2 tabs=200 mg), with an order date of 4/23/25.A review of the Behavior/Intervention Monthly Flow Record (BIMFR) for May 2025, revealed:-Behavior: Hallucinations and agitations. Interventions (were listed). Outcome Codes (OC) were listed. S/E: there was no listed S/E to monitor. The BIMFR had a blank for both target behaviors listed on the evening shifts for 5/10/25, 5/12/25, and 5/16/25.-Behavior: Poor appetite and daytime lethargy. Interventions (were listed). OC were listed. S/E: there was no listed S/E to monitor. The BIMFR had a blank for both target behaviors listed on the evening shifts of 5/10/25 and 5/16/25, and on the day shifts of 5/12/25 and 5/23/25. -Behavior: Sadness and refusing care/meds. Interventions (were listed). OC were listed. S/E: there was no listed S/E to monitor. The BIMFR had a blank for both target behaviors listed on the evening shifts of 5/10/25 and 5/16/25, and day shift of 5/12/25.2. On 6/16/25 at 10:41 AM, S#1 observed Resident #75 lying on bed. S#1 reviewed the medical records of Resident #75, and revealed the following:A review of the resident's hospital records, dated 1/29/24 Visit Note, by the hospital physician, revealed:-Assessment and Plan: Dementia in other diseases classified elsewhere, moderate, with psychotic disturbance. -Diagnosis: included but was not limited to Dementia in other diseases classified elsewhere, moderate, with psychotic disturbance.Further review of the hospital records, the physician documented on 12/11/23, under diagnosis, included but not limited to hallucinations, resident was having auditory hallucinations .A review of the AR revealed that Resident #75 was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, heart failure, type 2 diabetes mellitus without complications, and chronic kidney disease stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of blood) unspecified.A review of Resident #75's most recent cMDS, with an ARD of 3/3/25, had a BIMS score of 6 out of 15, indicating severe cognitive impairment. Section I: Active Diagnosis, included but not limited to non-Alzheimer's dementia, heart failure, diabetes mellitus, renal insufficiency, renal failure, ESRD (end stage renal disease), depression, and psychotic disorder.A review of the active CP revealed that the resident had a focus CP that included but not limited for the following:-use of antidepressant med r/t depression and insomnia that was initiated on 2/23/24.-use of antipsychotic med r/t paranoia and irrational fears that was initiated on 2/23/24.-had a behavior problem r/t behavior: suspicious ., pacing back and forth, exit seeking, and wanting to go home ., that was initiated on 2/26/24.-had depression r/t dementia with hallucination that was initiated on 3/4/24.-was on elopement risk/wanderer, disoriented to place, impaired safety awareness, resident wanders aimlessly voice wanting to go home, that was initiated on 2/26/24.Further review of the above CP revealed the resident had an intervention that included but not limited to the following:-identify potential s/e of the selected med & monitor for clinical appearance (e.g. falls, lethargy, cognitive decline, and physical decline), that was initiated on 2/23/24.-monitor location every 60 minutes, document wandering behavior, and attempted diversional interventions in behavior log, that was initiated on 2/26/24.A review of an active orders as of 6/19/25 in the OSR revealed a PO that included but not limited to the following:-A PO for trazodone HCL oral tab 100 mg, give 1 tab by mouth at HS for depression/insomnia, with an order date of 2/23/24.-A PO for risperidone oral tab 0.25 mg, give 1 tab by mouth every 12 hours (hrs) for psychosis, with an order date of 2/23/24.A review of the BIMFR for May 2025, revealed:-Behavior: Hallucinations and Delusions. Interventions (were listed). OC were listed. S/E: there was no listed S/E to monitor. -Behavior: Attempting to leave from the unit. Interventions (were listed). OC were listed. S/E: there was no listed S/E to monitor.-Behavior: Overwhelming sadness. Interventions (were listed). OC were listed. S/E: there was no listed S/E to monitor.-Behavior: Sleeplessness. Interventions (were listed). OC were listed. S/E: there was no listed S/E to monitor.Further review of the above BIMFR for May 2025, revealed, on 5/12/25 day shift for behaviors, interventions, outcome, and S/E were blank. The behavior for sleeplessness for day shift regarding number (#) of episodes and intervention from 5/1/25 through 5/31/25 were blank.On 6/18/25 at 12:06 PM, the survey team met with the Director of Nursing (DON). S#1 notified the DON of the above concerns about Resident #75 and #79's discrepancy with the omission in documenting in the BIMFR. On 6/19/25 at 10:01 AM, the survey team met with the DON. The DON stated that with regard to omissions of documentation, that she did not have anything to add, we tried to reach out to those responsible nurses, who were mostly agency nurses who did not filled out the BIMFR. 3. On 6/16/25 at 10:16 AM, Surveyor #2 (S#2) observed Resident #191 seated upright in bed. A review of Resident #191's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and hypertension (high blood pressure). A review of Resident #191's OSR included the following POs:-Aripiprazole (an antipsychotic used to treat schizophrenia, bipolar disorder, depression, and Tourette syndrome) 2 mg, give 0.5 tab by mouth at HS for bipolar disorder. Give with 1 tab=2 mg for total dose of 3 mg.-Aripiprazole 2 mg give 1 tab by mouth at HS for bipolar disorder. Give with 0.5 tab=1 mg for total dose of 3 mg.-Bupropion Hcl ER (XL) (an antidepressant) 150 mg, give 1 tab by mouth OD for bipolar disorder.-Clonazepam (produces a calming effect on the brain and nerves, which helps to reduce anxiety, prevent seizures, and promote relaxation) 0.125 mg, give 1 tab by mouth at HS for anxiety.-Clonazepam 0.125 mg, give 1 tab by mouth every 12 hours as needed (PRN) for anxiety until 6/26/25.-Lamotrigine (an anticonvulsant which can treat seizures and bipolar disorder) 200 mg, give 1 tab by mouth OD for bipolar depression.-Trazodone (antidepressant and sedative, used to treat depression, anxiety, and insomnia) 50 mg, give 0.5 tab by mouth at HS for depression with insomnia.On 6/17/25 at 10:40 AM, S#2 interviewed the Licensed Practical Nurse (LPN) regarding behavior monitoring. The LPN stated that when a resident was on a psychotropic med they would assess to see if there was any behaviors and monitor throughout the shift and would document it on the behavior monitoring sheets that were located in a binder. The LPN showed S#2 the behavior monitoring sheet for Resident #191. A review of the behavior monitoring sheets included the following:-The BIMFR for Lamotrigine had a blank for both target behaviors listed for monitoring on the night shift for 6/16/25. -The BIMFR for Bupropion had a blank for the target behavior listed on the night shift for 6/16/25. -The BIMFR for Clonazepam had a blank for the target behavior listed on the day shift for 6/15/25, and the night shift for 6/16/25.-The BIMFR for Trazodone had a blank for both target behaviors listed on the day shift for 6/14/25 and 6/15/25, and for the night shift on 6/16/25. -The BIMFR for Abilify (Aripiprazole) had a blank for both target behaviors listed on the evening shift for 6/13/25, and the night shift for 6/16/25, and for one of the behaviors on the day shift for 6/16/25.S#2 asked the LPN about the blanks on several shifts. The LPN stated that sometimes the nurse missed it. On 6/18/25 at 9:48 AM, S#2 interviewed the DON regarding behavior monitoring. The DON stated that behavior monitoring was documented on paper for all three shifts. She added that the expectation was that each shift should be filled out. The DON stated that she was aware that there was an occasional omission and that she would try to follow up with the nurse in a timely manner. On 6/18/25 at 12:12 PM, S#2 notified the DON the concern that Resident #191's behavior monitoring documentation for several psychotropic meds including an antipsychotic had several shifts that were blank. 4. On 6/16/25 at 10:08 AM, S#2 observed Resident #192 seated in a w/c accompanied by a private duty aid. A review of Resident #192's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dementia with mood disturbance (a condition characterized by cognitive decline, can significantly impact a person's mood and behavior, leading to mood disturbances like depression, anxiety, irritability, and apathy), psychosis (a mental state where a person loses contact with reality, often experiencing hallucinations (seeing or hearing things that aren't there), and delusions (false beliefs)) and congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should).A review of Resident #191's OSR included the following PO:-Escitalopram (an antidepressant) 10 mg, give 1 tab by mouth OD for depression.-Risperidone (second-generation antipsychotic (SGA), also known as an atypical antipsychotic, that affects brain chemicals like dopamine and serotonin to help with thinking, mood, and behavior) 0.25 mg, give 1 tab by mouth OD for psychosis. On 6/17/25 at 10:40 AM, S#2 interviewed the LPN regarding behavior monitoring. The LPN stated that when a resident was on a psychotropic med they would assess to see if there were any behaviors and monitor throughout the shift and would document it on the behavior monitoring sheets that were located in a binder. The LPN showed S#2 the behavior monitoring sheet for Resident #192. A review of the behavior monitoring sheets included the following:-The BIMFR for escitalopram had a blank for the target behavior listed on the evening shift for 6/11/25 and on the night shift for 6/16/25. -The BIMFR for Risperodone had a blank for the target behavior listed on day shift for 6/7/25, on the evening shift for 6/11/25, and on the night shift for 6/16/25. On 6/18/25 at 12:12 PM, S#2 notified the DON the concern that Resident #192's behavior monitoring documentation for two psychotropic meds including an antipsychotic had several shifts that were blank.On 6/19/25 at 10:04 AM, the DON stated that if there was an omission that she would go to great lengths to try to track down the nurse to ensure accurate documentation. The DON provided S#2 a copy of an inservice given to nursing staff that was provided regarding the concern.A review of the facility's Psychotropic Medications Policy with a revised date of 6/6/23, included the following:Purpose: To establish a system for assuring proper use and monitoring of psychotropic meds.Policy:1. For the purpose of this policy, a psychotropic med is any drug prescribe with the goal to alter behavior, mood, thoughts and/or perceptions.a. Examples of subclasses of psychotropic meds include: antidepressants, antipsychotics .2. PO are required for the use of all psychotropic meds. a. Psychotropic meds shall only be used as part of a plan to eliminate/reduce specific symptoms and/or to treat a specific diagnosis .5. Monitoring Use of Psychotropic Medsa. Nurses shall monitor every shift for resident-specific target behavioral, mood, thought and/or perception issues, as well as adverse reactions to the psychotropic med, and document specific occurrences of these issues.i. Each month, the nurse shall summarize the occurrences of relevant symptoms and adverse effects, if applicable .A review of the facility's Medical Records Policy with a revised date of 9/18/23, included the following:Purpose: The facility shall maintain an individual medical record for each resident during their stay at the facility and after discharge .It is the facility's responsibility to maintain the medical record's integrity, safety and confidentiality.Policy: .2. The information within the medical record shall be maintained as a combination of electronic documents .as well as hardcopy documents from various sources .6. Information within the medical record may be used by the facility or its representatives to satisfy reporting requirements as per pertinent local, state and federal regulations.On 6/23/25 at 11:13 AM, the survey team met with the DON, Directory of Dietary, Medical Director, and Infection Preventionist Nurse for an exit conference, there was no additional information provided by the DON.NJAC 8:39-23.2 (a)(b); 34.1(b); 35.2

Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 1 of 6 staff (Certified Nursing Aide) and b.) ensure laundry area maintained clean and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. According to the CDC information on the Sequence for putting on PPE, How to safely remove PPE: There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials . Here is one example. Remove all PPE before exiting the patient room . 1. On 6/16/25 at 10:44 AM, the surveyor observed the Certified Nursing Aide (CNA) came out of Resident room [ROOM NUMBER] (RR#101) with gloves, walked the hallway while removing gloves. The CNA did not perform hand hygiene after removing gloves and prior exiting RR#101. Afterward, the surveyor observed the CNA knocked the door of Resident room [ROOM NUMBER] (RR#109). Inside RR#109, the surveyor observed the CNA turned off the call light and came out of RR#109 without performing hand hygiene. Outside the room, the surveyor interviewed the CNA, who informed the surveyor that she came out of RR#101 after spreading the bed post changing sheet of the resident. The CNA confirmed that she had both gloves and did not remove gloves until she walked in the hallway and went to RR#109 to turn off the call light. She stated that she should have removed gloves inside RR#101, and performed hand hygiene prior to exiting the resident's room. The CNA had no answer as to why she did not remove gloves inside RR#101, and perform hand hygiene. On 6/16/25 at 10:51 AM, the surveyor immediately notified the Licensed Practical Nurse (LPN) with regard to above concerns with the CNA. The LPN stated that in reality, the gloves should be removed inside the resident's room and immediately perform hand hygiene post removal of gloves or PPE. She further stated that she would educate the CNA. 2. On 6/19/25 at 8:53 AM, the surveyor with the Director of Building Services (DBS) toured the basement laundry area. Both the surveyor and the DBS observed in the basement hallway there were linen carts. The DBS informed the surveyor that they were considered clean linen carts. The following were observed: -The 1st cart cover had a dried brownish substance. The 1st cart's second tier had clean pillows and there was a dried brownish substance, consistent to the same dried discoloration in the cover of the cart. The DBS acknowledged the dried brownish substance and discoloration, and stated that it should have been cleaned. There was a brown stain in the paper towel used by the DBS when attempted to clean it off. -The next linen cart also with brownish stain and accumulation of dust. The cart also had clean pillows. -Inside the folding area, the DBS informed the surveyor that the room was considered clean room where linens and other supplies were being dried and folded. Upon entry, both the surveyor and the DBS observed a table used for folding blankets and socks. On top of the folding area were uncovered clean folded blankets and socks was a pipe with accumulation of grayish substance. The DBS stated they were accumulation of dust and should have been cleaned. -Next to the folding table was the four tier cart with folded clean linens, towels, and gowns. The second level linen cart with clean supplies of towels and linens had one plastic container of water. The DBS took the plastic container of water and stated that the water was almost empty, and immediately threw it in the garbage. The DBS did not respond when asked why the plastic container of water was near the clean supplies. -There was another folding table at the end of the room with uncovered clean folded blankets and clean heel booties. Above the folding table was a pipe which the DBS claimed that at the end of the pipe was a bleeder with accumulation of dust. The DBS stated that the bleeder was for the hot mist and should have been cleaned. At that same date and time, the DBS informed the surveyor that the laundry area should have been cleaned daily and maintained clean by the Laundry or Housekeeping Staff while the high dusting should have been cleaned by the Maintenance Staff. The DBS confirmed that there was no accountability log for the daily cleaning of the laundry area and the linen carts. On 6/19/25 at 10:01 AM, the survey team met with the Director of Nursing (DON). The DON stated that she would get back to the surveyor with regard to the surveyor's concern with CNA's hand hygiene and PPE use. The surveyor notified the DON of the above concerns in the laundry area. On 6/19/25 at 12:34 PM, the surveyor interviewed Infection Preventionist Nurse (IPN), who informed the surveyor that it was her responsibility as an infection preventionist to oversee and tour the facility with regard to infection control. She also stated that she was responsible for the education and competency training of staff for hand hygiene and PPE use. She further stated that herself, the DON, Licensed Nursing Home Administrator, and the DBS tour the entire facility to look for potential problem with regard to infection control. The surveyor notified the IPN of the above findings and concerns with the CNA and the laundry area. On 6/23/25 at 10:17 AM, the survey team met with the DON. The DON stated we made an update to the log to include a check off for the high dusting, and made sure the linen cart was wiped down. The DON further stated that the DBS stated that he addressed all the concerns in the laundry after surveyor's inquiry. A review of the facility's Hand Hygiene in the Long Term Care Setting Policy that was provided by the DON, with a revised date of 10/18/24, revealed, to decrease the risk of transmission of infection by appropriate hand hygiene . A review of the facility's Infection Control Surveillance Policy that was provided by the DON, with a revised date of 10/18/24, revealed . Procedure: 2. Surveillance activities may include, but are not limited to: a. rounding on units and/or residents/staff . A review of the facility's Building and Services Policy that was provided by the DBS, with revised date of January 2024, revealed . Purpose: to maintain a clean, safe, and sanitary environment for all residents, staff, and visitors in accordance with regulatory standards and facility expectations. Policy: environmental services staff will follow standardized cleaning and maintenance practices to ensure all areas of the facility are hygienic, orderly, and properly maintained . Procedure: 2. Surface cleaning: dust and clean moldings, pipes, clocks, pictures, closet interiors/exteriors, and other high-touch or visible areas . 3. Detail cleaning: after completing high dusting tasks, mop and clean the floor to remove any residual dust or debris . On 6/23/25 at 11:13 AM, the survey team met with the DON, Director of Dietary, Medical Director, and IPN for an exit conference and there was no additional information provided by the DON. NJAC 8:39-19.4(a)(1)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 2 of 5 Certified Nurse Aides (CNAs) reviewed for mandatory education (CNA #1 and #2). This deficient practice was evidenced by the following: On 6/16/25 at 1:03 PM, the surveyor requested from the Director of Nursing (DON) the annual education that was done for 5 randomly selected CNAs based on their date of hire (doh). A review of the facility provided annual education transcripts included the following: CNA #1, with a doh of 3/11/16, did not have QAPI training. CNA #2, with a doh of 4/29/24, did not have QAPI training. On 6/19/25 at 10:54 AM, the surveyor interviewed the Wound Care Nurse/Educator (WCN/E) regarding education. The WCN/E stated that the QAPI training was more of a meeting that was handled by the DON. On 6/19/25 at 11:11 AM, the WCN/E confirmed that 2 of 5 CNAs did not have QAPI training on the facility provided transcripts. On 6/19/25 at 11:25 AM, the DON confirmed that 2 of 5 CNAs did not have QAPI training on the facility provided transcripts. She stated that there was facility wide education of PIPs (Performance Improvement Plans) they were currently working on. The DON then looked through the binder and stated that she found a PIP inservice that CNA #2 was listed on for EBP (Enhanced Barrier Precautions). The surveyor reviewed the inservice sheet and it only documented EBP. The sheet did not indicate that it was a PIP for QAPI. The inservice was also listed on CNA #2's transcript as EBP on 11/15/24, and did not indicate that it was related to QAPI. The DON added that she did not locate an inservice for CNA #1. On 6/19/25 at 12:01 PM, the surveyor notified the DON of the concern that CNA #1 and CNA #2 did not have QAPI training. On 6/23/25 at 10:17 AM, the DON stated that CNA #1 attended a PIP. She added that they have four ongoing PIPs. The DON stated that they do facility wide training on the process of QAPI and that each PIP was further education. The surveyor asked if CNA #1 and #2 had the facility wide QAPI training. The DON stated that it did not look like they had the facility wide training for QAPI. The DON did not provide any additional information. A review of the facility's Education and Core Competency Training for Nursing Staff Policy with a revised date of 7/18/24, included the following: 3. CNAs are required to complete 12 hours of continuing education annually. 5. All nursing staff must attend mandatory facility in-services annually, and as needed. Topics include: LGBTQIA (lesbian, gay, bisexual, transgender, queer) + training; residents' rights; abuse/neglect prevention; infection control; HIPAA (Health Insurance Portability and Accountability Act); and life safety (e.g. fire/evacuation drill). The policy did not contain any information on QAPI training. A review of the facility's Quality Assurance Performance Improvement (QAPI) with a revised date of 3/14/23, included the following: 1 b. Governance & Leadership- .The Administrator, DON, and Quality Assurance/Staff Educator will be accountable for QAPI, which will include leadership training for the entire facility. The policy did not contain any other information on QAPI training. N.J.A.C. 8:39-33.1

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 2 of 9 medication carts inspected. This deficient practice was evidenced by the following: On 8/4/21 at 9:15 AM, the surveyor inspected the Heritage West medication cart #2 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened Novolog Insulin that did not contained a label with a resident's name. At that time, the surveyor interviewed LPN #1 who stated that the Novolog insulin pen should have contained a label with the resident's name. On 8/4/21 at 10:15 AM, the surveyor inspected the Heritage East medication cart #2 in the presence of LPN #2. The surveyor observed an opened vial of [MEDICATION(S)] insulin that did not contained a label with a resident's name. At that time, the surveyor interviewed LPN #2 who stated that the [MEDICATION(S)] insulin vial should have contained a label with the resident's name. On 8/4/21 at 1:15 PM, the surveyor met with the Administrator and the Director of Nursing (DON) and no further information was provided by the facility. A review of the facility's policy for Medication Labels dated 12/17/20 that was provided by the DON indicated the following: 1. Labels are permanently affixed to the outside of the prescription container. No mediation is accepted with the label inserted into a vial. If a label does not fit directly onto the product, e.g eye drops, the label may be affixed to an outside container or carton, but the resident's name must be maintained directly on the actual product container. and 2. Each prescription medication label includes: a). Resident's name. A review of the facility's policy for Medications from Home dated 9/7/20 that was provided by the DON indicated the following: b). Verify that the medication is in the original manufacturer/outside pharmacy packaging; and d). For home medications from an outside pharmacy, verify that the medication is properly labeled by an outside pharmacy as per current state/federal labeling regulations for prescription medication. NJAC: 8:39-29.4 (a) (h) (d)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner in order to prevent contamination from foreign substances and potential for the development of a foodborne illness. This deficient practice was evidenced by the following: On 9/12/19 at 9:20 AM, in the presence on the Food Service Director (FSD) the surveyor observed the following: 1. The three-door refrigerator did not have a thermometer inside the refrigerator. 2. The over flow milk refrigerator did not have a thermometer inside the refrigerator. The FSD stated, the staff cleaned the refrigerators last night and did not put the thermometers back in. The FSD further stated that they go through many thermometers in this way. The surveyor reviewed the temperature logs for the above two refrigerators. The temperature log documented on 9/12/19 at 8:00 AM that the temperature of the cooks reach in refrigerator was 40 degrees and the kitchen milk refrigerator at 8:00 AM was 37 degrees. The surveyor asked the FSD how the staff documented the temperatures at 8:00 AM, if the thermometers were not inside the two refrigerators at that time. The FSD stated, They probably read the temperatures on the thermometers that were on the outside of the refrigerator. 3. A bottle of honey and a gallon of water were on a tray that had food crumbs on it. 4. Convection oven #1 had dried brown drippings on both glass doors and the four oven knobs had a buildup of a brown grease like substance. 5. Convection oven #2 had dried brown drippings on both glass doors and the four oven knobs had a buildup of a brown grease like substance. 6. Oven #1 had a buildup of a brown, black grease like drippings on the backsplash and the six oven knobs had a build-up of a brown grease like substance. 7. Oven #2 had six knobs that had a buildup of a brown grease like substance. 8. The knob of the steamer had a buildup of a brown grease like substance. The FSD told the surveyor that the outside of the ovens and steamer were cleaned daily. The surveyor reviewed the form titled, Dietary Department Daily Cleaning Assignments, that was posted on the window outside of the FSD's office door. There was no date written on the weekly form and no staff signatures next to the cleaning assignments from the past Monday through Thursday. The area for the Supervisor initials was left blank. The surveyor asked the FSD where the staff sign when they complete their cleaning assignments. The FSD stated, They don't sign anything. The FSD further stated that she or her supervisor double checks that the daily cleaning assignments are completed, however the FSD was unable to provide written documentation of the completion of the daily cleaning assignments done by the kitchen staff. A review of the facility's policy titled Food Storage indicated under Procedure #5, All refrigerators will have and internal thermometers to monitor for safe food storage temperatures. Units must maintain safe internal temperatures 32 degrees Fahrenheit to 41 degrees Fahrenheit. The surveyor requested the policy and procedure for sanitation of kitchen equipment from the FSD. The FSD gave the surveyor the facility's form titled Cleaning of Stovetop that indicated under #1: After each use the stovetop will be cleaned to ensure sanitary conditions. And under #2 and #3 indicated: After use, remove knobs and soak in soapy water and scrape excess loose soil from surface with a spatula or grill scraper. The FSD told the surveyor they did not have a policy and procedure for sanitation of kitchen equipment. On 9/12/19 at 1:30 PM, the surveyor discussed the above concerns with the Administrator and Director of Nursing. No further information was provided. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan (CP) to address the respiratory care needs for 1 of 2 residents (Resident #12) reviewed. The deficient practice was evidenced by the following: On 11/8/18 at 11:44 AM, the surveyor observed Resident #12 seated in the wheelchair watching television. The surveyor also observed an Oxygen Concentrator in Resident #12's room with the Oxygen tubing and nasal cannula stored in a plastic bag. The surveyor reviewed Resident #12's medical records. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed Resident #12's physician's orders [REDACTED]. Resident #12 had a CP initiated on 8/2/18 for [MEDICAL CONDITION]. A review of the CP interventions revealed there was no intervention incorporating the use of Oxygen that was ordered on [DATE]. In addition the facility did not develop a CP to address Resident #12's potential need for Oxygen. On 11/14/18 at 11:00 AM, the surveyor interviewed the nurse assigned to Resident #12 who stated that all physician orders [REDACTED]. [REDACTED].>On 11/14/18 at 11:10 AM, the surveyor interviewed the MDS (Minimum Data Set) Coordinator who also stated that all physicians orders are added to the care plan by the nurse who obtained the order from the physician. The MDS coordinator also stated that the care plans are reviewed for accuracy by the Unit Manager and Interdisciplinary Team. On 11/14/18 at 12:45 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated that Resident #12 had an order for [REDACTED]. A review of the facility's policy for Oxygen Therapy Policy did not include information regarding Oxygen orders being entered in the care plan. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to properly store, label and dispose of medications in 2 of 10 medication carts and 1 of 4 medication refrigerators inspected. This deficient practice was evidenced by the following: On 11/8/18 at 9:15 AM, the surveyor inspected the Reflection Unit medication cart #2 in the presence of a License Practical Nurse (LPN). The surveyor observed one opened vial of Humalog Insulin that was not dated. The surveyor interviewed the LPN who stated that all opened vials of insulin should be dated. On 11/8/18 at 9:20 AM, the surveyor inspected the Reflection unit medication refrigerator in the presence of a Registered Nurse (RN). The surveyor observed an opened vial of [MEDICATION NAME] Purified Protein Derivative (PPD) and one opened bottle of [MEDICATION NAME] 2 mg/ ml solution that were not dated. The surveyor interviewed the RN who stated that all opened bottles of [MEDICATION NAME] and opened vials of PPD should be dated. On 11/8/18 at 9:30 AM, the surveyor inspected Heritage unit medication cart #1 in the presence of LPN #2. The surveyor observed an opened bottle of Blood Glucose Test strips that was not dated. The surveyor interviewed LPN #2 who stated that all opened bottles of Blood Glucose Test strips should be dated. A review of Manufacturer's Specifications for the above medications revealed the following: 1. Humalog Insulin vials once opened have an expiration date of 28-days 2. PPD vials once opened have an expiration date of 30-days. 3. [MEDICATION NAME] solution bottles once opened have an expiration date of 90-days. 4. Blood Glucose Test strips once opened have an expiration date of 90-days. A review of the facility's undated policy titled, Storage of Medications, indicated that certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, [MEDICATION NAME] tablets, once opened, require an expiration date shorter than the manufacturer's expiration to ensure medication purity and potency. NJAC: 8:39-29.4 (a) (h) and (d)

Based on observation, interview and record review, it was determined that the facility failed to maintain professional standards of clinical practice by not following the physician's orders [REDACTED]. This deficient practice was observed for 1 of 19 residents (Resident #11) reviewed. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: The surveyor reviewed Resident #11's records on 10/17/17. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the September and October 2017 Electronic Medication Administration (EMAR) which revealed an order for [REDACTED]. A review of the October 2017 EMAR documented the administration of Olmesarten Medoxomil 40 mg with documented DBPs on 9/23/17 with DBP of 55, on 9/26/17 with DBP of 57, on 10/3/17 with DBP of 55 and on 10/6/17 with DBP of 58, when the medication should have been held because it was less than 60. On 10/19/17 at 1 p.m., the surveyor discussed the above concerns with the Administrator and Director of Nursing (DON). The DON presented to the surveyor education in-services that were given to the nurses 1/2017, 6/2017 and 7/2017 regarding medications and parameters. However, the facility nurses continued to not follow the parameters according to the physician's orders [REDACTED]. NJAC 8:39- 29.2 (d)

Based on observation and interview on 9/22/16 in the presence of facility management, it was determined that the facility failed to maintain 3 of 4 commercial clothes dryer drums in safe and effective operating condition. This deficient practice was evidenced by the following: At 11:15 a.m., the surveyor observed in the commercial clothes dryer room that 3 of 4 dryer drums had an unknown plastic-like substance embedded into the drum vents. The unknown substance covered the heating vent holes in various locations of the drums. An interview was conducted at the time of the observation with the facility management who stated that the drums should not be like that in the facility and he would notify the manufacturer for advice on cleaning the drums properly. No maintenance log or policy and procedure were provided. NJAC 8:39-31.2(e) NJAC 8:39-31.4(b)

Based on observation and interview, it was determined that the facility failed to store potentially hazardous foods in a manner to prevent food borne illness, sanitize dishware in a manner to prevent cross-contamination of microbial growth and failed to maintain equipment in a sanitary manner. The deficient practice was evidenced by the following: On 09/21/16 at 8:45 a.m., in the presence of the Registered Dietitian (RD), the surveyor observed the following: 1. The surveyor observed the third compartment sanitizing sink with pots soaking. The RD used a ph test strip to test the sanitizing sink which only reached 100 parts per million (ppm). The RD used a second ph test strip which reached 100 ppm. The surveyor asked the RD if the sanitizing sink was tested prior to placing the pots inside. The RD told the surveyor that the sanitizer was tested twice a day. The surveyor reviewed the Pot Sink Sanitizer Test log which listed the normal ppm range to be 200 ppm and the log revealed that the sanitizing sink was scheduled to be tested in the afternoon and evening. According to the log, the sanitizer sink had not yet been tested for 9/21/16. 2. On a rack near the three-compartment sink, the surveyor observed 4 plastic storage containers wet and nested together. 3. In the ground level standing refrigerator # 3 the surveyor observed 26 containers of 4 oz skim milk without a stamped manufacturers date on each container. The RD said the containers should have use by dates. 4. On the shelves in the dry storage area the surveyor observed 6 dented cans. At 1 p.m. the surveyor discussed the kitchen concerns with the Administer and Director of Nursing. On 09/26/16 at 9:00 a.m., the Food Service Director (FSD)provided the surveyor with the facility's policy titled Sanitation & Log. The Policy stated, The Food Service Director is responsible for completing the AM Dietary Sanitizer Log. However, the FSD was unable to provide documentation that the sanitizer was checked in the a.m. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan to address nutritional and medical needs for 2 of 24 residents (#13 & #14) reviewed. The deficient practice was evidenced by the following: 1. On 7/14/15 at 12:20 p.m. the surveyor observed Resident #13 seated in a wheelchair in the resident's room. The resident told the surveyor that lunch was coming, but the resident did not have an appetite. At 2 p.m. the surveyor reviewed the resident's records. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Registered Dietician's (RD) notes revealed that the resident had weight loss. On 7/6/15 the RD recommended Ensure Plus as a supplement to be offered at 2 p.m. daily. The resident refused to drink the supplement. The RD recommended another supplement which the resident accepted. The RD also documented that the resident had a variable appetite. A review of the resident's care plans revealed that there was no care plan developed by nursing or the RD to address the resident's nutritional needs. On 7/15/15 at 9:30 a.m. the surveyor spoke to the RD. The RD said that she must have forgotten to develop a care plan. 2. On 7/14/15 at 1:15 p.m. the surveyor observed Resident #14 lying on top of the bed asleep. On 7/15/15 at 8:30 a.m. the surveyor reviewed the resident's records. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident also only had one functioning kidney. The surveyor reviewed the Interval Progress Note dated 6/25/15 - 7/14/15, where the resident's primary care physician documented that the resident's kidney function was being monitored and that the resident was being followed by a Nephrologist. A review of the July 2015 physician's orders [REDACTED]. The order was discontinued on 6/29/15. A review of the Comprehensive Metabolic Panel dated 6/26/15 - 7/13/15 revealed that the resident had high to critical Blood Urea Nitrogen (BUN) levels and high Creatinine levels (indicators of kidney function.) A review of the resident's care plan revealed that there was no comprehensive care plan developed to address the resident's medical needs related to the resident's [DIAGNOSES REDACTED]. At 12:30 p.m. the surveyor asked the charge nurse (CN) about the resident's care plans. The CN and surveyor reviewed the care plans listed. The CN said that the nurse who admits the resident would develop the care plans. She did not know why a comprehensive care plan was not developed. NJAC-8:39-27.1(a)

Based on observation, interview and review of the medical record, it was determined that the facility failed to ensure that residents were administered the correct medication and the correct dose as well as have a system in place to ensure physician's orders were accurately transcribed into the electronic Medication Administration Record (eMAR). This deficient practice was noted for 8 of 27 residents reviewed for medications reconciliation. This resulted in an immediate jeopardy situation for Residents #1, #5, #7, #13, #15, #17, #20, and #25 who had physician orders for medication, but the electronic eMAR did not have the same medication/dose to be administered as the physician's order was written. The failure to provide accurate medications as ordered by the physicians placed the residents' welfare at risk of injury or death. The immediate jeopardy was identified on 7/23/13 at 9:10 a.m. and the facility was notified. A Plan of Correction was submitted by the facility and accepted on 7/23/13 at 2:10 p.m. based on actions taken, including in-service training to nurses regarding transcribing physician's orders, clarification of orders, and order entry into the eMAR. Additional action was taken to allow the provider pharmacy access to the eMAR to ensure that the physician's order entered by the nurse matched what was dispensed by the pharmacy provider. The pharmacy will review orders entered into the eMAR system, a trash run of all high risk medications to ensure proper (physician) order entry, and review all Physician Order Sheets (POS) to reconcile to the eMAR by nursing, the pharmacy provider and the pharmacy consultant. The surveyors verified the completion of the plan of correction on 7/24/13 at 3 p.m. and the immediacy was abated. This deficiency was corrected on 7/24/13 at 3 p.m. This deficient practice was evidenced by the following: 1. During the tour of the Heritage Unit on 7/10/13 at 11:45 a.m. with the Licensed Practical Nurse (LPN), the surveyor was informed that Resident #5 was alert, oriented, and forgetful. The resident was ambulatory, complained of back pain for a few months and had a recent lumbar fracture, and was on pain management. The surveyor reviewed the medical record on 7/12/13 at 10:40 a.m. The Physician's Order Sheet (POS) had an order for [REDACTED].#5's lower back once daily, in the a.m. for 12 hours, off in the p.m. for 12 hours. The surveyor reviewed the eMAR and observed that the order was not transcribed as written by the physician. The eMAR read that a [MEDICATION NAME] Patch 5% was to be applied to the lower back every morning and again at bedtime for pain. This transcription error doubled the dose of the medication and the part of the order concerning the removal of the patch was omitted. The eMAR documented that the double dose of medication was given from 7/1/13 to 7/12/12. A patch was documented as applied at 8:30 a.m. and again at 8:30 p.m. There was no documentation that a patch was removed as per the physician's order. Excessive dosing by applying [MEDICATION NAME]es for longer than the recommended wearing time could result in increased absorption of [MEDICATION NAME] and high blood concentrations, leading to serious adverse effects. Adverse effects could include nervousness, euphoria, confusion, dizziness, blurred vision, vomiting, twitching, tremors, convulsions, respiratory depression and respiratory arrest. Cardiovascular manifestations might include slow heart rate, low blood pressure and cardiovascular collapse leading to [MEDICAL CONDITION]. During an interview with the Administrator and Assistant Administrator on 7/12/13 at 3 p.m., the Assistant Administrator stated there was a glitch in the computer system which did not allow the staff to write the medication differently. However, the surveyor reviewed the April 2013 eMAR and observed that this order was written as apply a [MEDICATION NAME] Patch 5% to the lower back every morning related to unspecified backache, OFF(remove) at hour of sleep. 2. During tour of the Horizon's East unit with the Registered Nurse Charge Nurse on 7/10/13 at 10:50 a.m., the surveyor was informed that Resident #15 was alert and oriented and went for [MEDICAL TREATMENT] 3 days per week. The surveyor reviewed Resident #15's medical record on 7/12/13. There was a physician's order for [MEDICATION NAME], a medication for constipation, 100 mg twice a day. This order appeared on the eMAR as [MEDICATION NAME] Capsule 100 mg to be given only at bedtime. The order on the eMAR cut the dose ordered by the physician in half. 3. On 7/11/13 at 11:57 a.m. the surveyor reviewed the medical record including the eMAR and Physician's orders for Resident #13 who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor noted that on 4/15/13 the physician ordered the [MEDICAL CONDITION] prevention medication [MEDICATION NAME] Suspension 125 mg per 5 ml and to administer 125 mg 3 times a day. On 7/8/13 the physician decreased the [MEDICATION NAME] to 100 mg equaling 4 ml 3 times a day. On 7/11/13 at 12:45 p.m. the surveyor observed the LPN administer the 12:30 p.m. [MEDICATION NAME] dose. The eMAR for Resident #13 contained the new order for [MEDICATION NAME] 100 mg orally three times a day. The label on the bottle of [MEDICATION NAME] suspension that the nurse retrieved from the medication cart indicated this bottle of [MEDICATION NAME] suspension was delivered by the provider pharmacy on 7/7/13 and that each 5 ml contained 125 mg. The label also noted that the resident should receive 5 ml/125 mg by mouth three times daily. The nurse then poured 5 ml of [MEDICATION NAME] and administered it to Resident #13. The 125 mg dose was incorrect, as on 7/8/13 the physician had lowered the dose to 100 mg 3 times a day. [MEDICATION NAME] overdosing might cause respiratory distress, tremors, agitation, hallucinations and abnormal gait. The elderly are at greater risk for toxicity because of impaired metabolism and decreased protein binding. On 7/11/13 at 1:12 p.m. the surveyor interviewed the Registered Nurse (RN) in Charge. The nurse stated that "the order on the eMAR should have had the concentration of the liquid " and that the eMAR would be corrected. The RN also indicated she would contact the Provider Pharmacy to send a new bottle of the medication. 4. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. At 10 a.m. the surveyor reviewed the POS which revealed the initial order for [MEDICATION NAME] ER 20 mg 1 tablet orally every 12 hours for pain was dated 7/10/13. The surveyor noted that the eMAR order for the [MEDICATION NAME] read to give 1 tablet every 12 hours "as needed" for pain. The surveyor advised the RN in charge of the discrepancy between the order for every 12 hours routinely versus every 12 hours as needed. The order was corrected on the eMAR to show that the [MEDICATION NAME] was to be administered routinely at 8:30 a.m. and 10:30 p.m. During reconciliation of the medication pass on 7/11/13 at 10 a.m., Resident #17 was noted with a physician's order dated 7/10/13 for a [MEDICATION NAME] Patch 5% for pain to be applied to the left shoulder and each knee daily (on in the a.m. and off at bedtime) When the surveyor reviewed the eMAR, the 3 orders were documented as (1.) [MEDICATION NAME] Patch 5% Apply to Left Shoulder topically every morning and at bedtime for Pain - On in a.m., off in p.m.;(2.) [MEDICATION NAME] Patch 5% Apply to Left knee topically every morning and at bedtime for Pain - On in a.m. off in p.m.; and (3.) [MEDICATION NAME] Patch 5% Apply to Right knee topically every morning and at bedtime for Pain - On in a.m. off every p.m. to be administered at 8:30 a.m. and 10:30 p.m. On 7/16/13 at 9:48 a.m. the surveyor counted the number of [MEDICATION NAME]es left in the medication cart and the surveyor noted 14 patches remained in the box. The pharmacy label documented 30 patches were delivered to the facility for Resident #17. If the doses were administered properly, 15 patches should have been left in the box. The surveyors concern regarding the inaccurate number of patches remaining for Resident # 17 was discussed with the Administrator and Assistant Administrator on 7/15/2013 at 2:45 p.m.. There was no explanation for the discrepancy other than it was a "glitch" in the computer system. Resident #17 was observed by the surveyor in the rehab gym on 7/17/13 at 11:25 a.m. and during an interview the resident complained of pain. The POS was reviewed and there was a physician's order dated 7/10/13 which indicated that [MEDICATION NAME] 5/325 mg 1 tablet every 4 hours for moderate to severe pain was to be administered. There was also a new physician order dated 7/11/13 written on a prescription blank that read [MEDICATION NAME] with [MEDICATION NAME] 5/325 mg 1 tab every 4 hours as needed for mild pain and 2 tablets every 4 hours as needed for moderate to severe pain. The surveyor reviewed the eMAR and observed an order for [REDACTED]." This was not the order that the physician had written. On 7/17/13 at 12:17 p.m. the medication nurse stated to the surveyor that she was unaware of the physician prescription and said " the charge nurse should have taken off the order for 2 tablets and added it to the computer. " On 7/17/13 at 12:20 p.m. the surveyor interviewed the Horizon East RN in Charge who stated "whoever got the physical script should have updated the order." 5. During initial tour with the LPN Charge Nurse from Horizon's West on 7/10/13 at 10:00 a.m., the surveyor was informed that Resident #25 was alert, oriented, immobile in room and received therapy for assistance with walking. The surveyor reviewed Resident #25's medical record on 7/18/13. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. There was a physician's order for the anticoagulant medication [MEDICATION NAME]. On 7/12/13 the Physician ordered [MEDICATION NAME] 2 mg orally every Monday, Tuesday, Thursday, Friday and Saturday at bedtime and [MEDICATION NAME] 2.5 mg orally every Sunday and Wednesday. On Thursday, 7/18/13 at 3:32 p.m. the surveyor examined the [MEDICATION NAME] in the medication cart for this resident. The surveyor, in the presence of the LPN, found only a box of [MEDICATION NAME] 2.5 mg with 5 tablets remaining. According to the label the Provider Pharmacy sent 8 Couomadin pills on 7/12/13. According to the eMAR only 2 doses of [MEDICATION NAME] 2.5 had been administered; 1 dose on 7/14/13 and 1 dose on 7/17/13. If 8 pills were delivered and 2 pills were given there should be 6 pills reamining instead of the 5 found by the surveyor. On 7/18/13 at 2:36 p.m. when the surveyor asked to see the [MEDICATION NAME] 2 mg tablets, the LPN could not find any [MEDICATION NAME] 2 mg tablets in the medication cart. A dose of [MEDICATION NAME] 2 mg was due to be administered on Thursday 7/18/13 at 10:30 p.m. and the surveyor questioned the LPN regarding what would be done if there was no medication in the cart for the next dose of medication. On 7/18/13 at 4:02 p.m. the LPN notified the surveyor that [MEDICATION NAME] 2 mg would be taken from the back up medication supply for administration that evening at 10:30 p.m. to Resident #25. The pharmacy delivered a new order of [MEDICATION NAME] 20 of 2 mg each on 7/18/13 at 8:25 p.m. [MEDICATION NAME] must be monitored closely and frequent laboratory testing must be done. Overdosing of [MEDICATION NAME] could cause increased bleeding and lead to death in a resident. Underdosing or failure to maintain a therapeutic level of the medication could cause increased blood clotting leading to stroke or death. On 7/22/13 at 11:22 a.m. the surveyor called the Provider Pharmacy to get a list of all [MEDICATION NAME] Tablets that had been sent for Resident #25. The representative from the Provider Pharmacy faxed a print out list on 7/22/13 at 12:10 p.m. of all the [MEDICATION NAME] delivered to the facility. On 7/5/13 - 30 tablets of [MEDICATION NAME] 2 mg were delivered. The surveyor reviewed the eMAR which indicated that 11 doses were administered from 7/5/13 to 7/16/13 which meant that 19 doses should still be available for administration. There were no 2 mg doses in the medication cart on 7/18/13. No explanation from the Administrator or Assistant Administrator was given to clarify the missing doses. 6. During tour of the Reflections Unit with the RN in charge on 7/10/13 at 11:30 a.m., the surveyor was informed that Resident #20 was alert and oriented with some forgetfulness. The surveyor reviewed Resident #20's medical record on 7/15/13 at 12:30 p.m. which noted that Resident # 20 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #20's POS revealed that the physician wrote an order for [REDACTED]. 1. On 2/1/13 start [MEDICATION NAME] 5 milligrams (mg.) and increase to 10 mg in 1 week . 2. On 2/8/13 [MEDICATION NAME] 10 mg tablet, take 1 by mouth daily at hour of sleep (HS). 3. On 6/24/13 [MEDICATION NAME] 15 mg by mouth HS. The surveyor reviewed the medication cart on 7/15/13 at 2:23 p.m. and observed that the pharmacy sent [MEDICATION NAME] 10 mg and 5 mg to equal a 15 mg dose. This was done as [MEDICATION NAME] does not come in a 15 mg tablet. On 7/15/13 at 2:23 p.m., the surveyor pharmacist and the medication nurse reconciled the quantities of [MEDICATION NAME] received from the pharmacy, the [MEDICATION NAME] administered to Resident #20, and the [MEDICATION NAME] that remained in the cart. The surveyor noted that the pharmacy delivered 30 doses of [MEDICATION NAME] 5 mg tablets on 6/24/13 and according to the e[DATE] doses of [MEDICATION NAME] 5 mg. were administered from 6/25/13 through 7/14/13. On 7/15/13 the surveyor noted that there were 15 doses of [MEDICATION NAME] 5 mg. still in the box in the medication cart instead of the 10 that should have been left and there were 5 doses of [MEDICATION NAME] 5 mg. tablets still in the medication cart. During review of the eMAR for June 2013, the surveyor noted that an additional dose of [MEDICATION NAME] 15 mg was administered to Resident #20 on 6/25/13 at 8:30 in the morning as well as the prescribed dose at HS. There was no documented evidence of a physician's order for the morning dose of [MEDICATION NAME] on that date. During an interview with the charge nurse on 7/22/13 at 10:45 a.m. and the Director of Nursing (DON) on 7/22/13 at 11:20 a.m., no physician's order was found, and no explanation was given for the extra dose administered to Resident #20 in the morning of 6/25/13. Review of the eMAR also revealed there was an omission of a dose of [MEDICATION NAME] on 6/24/13. During a review of the eMAR for the months of June 2013 and July 2013, the surveyor noted that the facility failed to document the administration of [MEDICATION NAME] 10 mg. 1 tablet, and [MEDICATION NAME] 5 mg. 1 tablet at HS. as 2 separate medications to clarify the administration of 2 tablets, each tablet of a different strength. 7. During tour of the Reflections Unit with the RN in charge on 7/10/13 at 10:20 a.m. the surveyor was informed that Resident #1 was alert and confused, takes an antidepressant and takes antipsychotic medications for behaviors of resistance to care.. The surveyor reviewed Resident#1's medical record on 7/11/13 at 1:45 p.m. and 7/12/13 at 11 a.m. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident#1's physician's orders revealed a 5/24/13 order for the antidepressant [MEDICATION NAME] 7.5 mg. The [MEDICATION NAME] was to be given at the hour of sleep. On 6/14/13 the [MEDICATION NAME] was increased to 15 mg. On 7/15/13 at 11:12 a.m., the surveyor pharmacist along with the charge nurse reconciled the quantities of medication received from the pharmacy with medication administered to Resident #1 as documented on the eMAR, and medication that remained in the medication cart. The surveyor noted: 1. On 5/24/13 the pharmacy delivered 30 doses of [MEDICATION NAME] 7.5 mg (15 mg half tablets = 30 tabs). 2. On 6/25/13 the pharmacy delivered 30 doses of [MEDICATION NAME] 7.5 mg (15 mg half tablets). At the time of the reconciliation on 7/15/13 at 11:12 a.m., a total of 60 doses of [MEDICATION NAME] 7.5 mg had been delivered. Only 58 doses had been administered. There were still 2 doses left in the box in the medication cart at 12:15 p.m. on 7/15/13. On 6/14/13, when the dose of [MEDICATION NAME] was increased from 7.5 mg to 15 mg, the facility continued to use the ? tablets that were sent from the pharmacy. The eMAR was changed to [MEDICATION NAME] Tablet give 15 mg by mouth at bedtime but should have indicated [MEDICATION NAME] 15 mg give (2) 7.5 mg half tablets to equal 15 mg. by mouth. 8. The surveyor reviewed the medical record for Resident #7 on 7/12/13 at 1:00 p.m. which indicated the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the eMAR for Resident #7 and noted a physician's order for [MEDICATION NAME] Solution 10 gm/15 ml give 30 ml by mouth every 24 hours as needed for constipation. The surveyor reviewed the signed, paper, POS on the medical record for June and July 2013. This order noted that the [MEDICATION NAME] was to be given TWICE a day. The order on the eMar was half the dose the physician had intended. On 7/15/13 at 2:45 p.m. the survey team met with the facility Administrator, Assistant Administrator, and Director of Nursing (DON) and discussed the [MEDICATION NAME] discrepancy. The Administrator, and the Assistant Administrator said they would look into it. On 7/16/13 at 10:10 administrative staff confirmed the physician's order for the [MEDICATION NAME] had been inaccurately transcribed on the E-MAR. NJAC 8:39-29.2 (d)

Based on observation and interview it was determined that the facility failed to monitor the implementation of a new system utilizing the electronic Medication Administration Record (eMAR) to determine the accuracy of the medication orders transcribed from the physician's orders [REDACTED]. The facility's Consultant Pharmacist performed monthly audits of the eMAR system but there was no evidence that this data collection was utilized to determine the root cause of the system's problems. The facility also failed to identify the findings of deficient areas in the eMAR system and present them to the quarterly Performance Improvement committee, put interventions into place when deficiencies were identified, and re-evaluate systemic changes for effectiveness. This deficient practice was noted for 7 of 12 months in 2013, from the initiation of the eMAR system in January 2013 until July 2013. The failure of the facility to have interventions in place after identifying medication errors placed the resident's welfare at risk of injury or death. The immediate jeopardy was identified on 7/25/13 at 3 p.m. after supervisory review of additional documentation submitted to the office by the facility. The facility was notified of the immediate jeopardy situation on 7/25/13 at 3 p.m. A Plan of Correction was submitted by the facility and accepted and the immediacy was abated on 7/25/13 at 4:20 p.m. based on actions taken which included the pharmacy review of each new order transcribed on the POS and entered into the eMAR to ensure properly transcribed orders; monthly meetings with Pharmacy Consultant and Provider, and Medical Director. The deficiency was corrected on 7/25/13 at 4:20 p.m. This deficient practice was evidenced by the following: The surveyor interviewed the licensed nurse on the Heritage Unit on 7/12/13 at 12:25 p.m. and was informed that the new system of the eMAR was initiated in the facility in January 2013. On 7/16/13 at 11:30 a.m. the Administrator told the surveyor that the facility did not have a Performance Improvement (PI) study when the facility started the new eMAR system . On 7/22/13 at 11 a.m. the facility provided the surveyor with the minutes of the quarterly PI Committee meetings held on 1/30/13 and 4/26/13, as well as the quarterly Pharmacy and Therapeutics (P&T) meetings held on 1/30/13 and 4/24/13. At the 1/30/13 quarterly P&T committee, which reviewed the facility information for the months of October, November and December 2012, the consultant pharmacy group reported: 421 medical records reviewed; 3 repeat recommendations (an increase); 43 transcription errors (an increase) ; and 6 administration errors. At the 4/24/13 quarterly P&T committee, which reviewed the facility information for the months of January, February, and March 2013, the consultant pharmacy group reported: 431 medical records reviewed; 31 repeat recommendations (an increase from 0.71% to 7.2%); and 140 transcription errors (an increase from 10.2% to 32.48%). The surveyor reviewed the minutes of the 1/30/13 PI meeting which identified medication errors as the "Topic" and the 'Action/Recommendation' stated "continue monitoring and address with staff as needed." There was no evidence that the facility had done tracking or trending of any documented findings from the results that were identified. During review of the 4/25/13 PI Committee Agenda , the surveyor noted that there was no documentation that medications, or medication errors, were discussed at the meeting. There was no crossover of information or findings from the identified concerns at the P&T committee to the PI committee. Although nursing inservices regarding medications were done during the Nurse Meetings held from 1/8/13 through 6/25/13, the medication concerns continued to appear on the eMAR. The surveyor interviewed the Administrator and Assistant Administrator on 7/15/13 at 3 p.m. who confirmed that the facility required the nursing staff on the 11-7 shift to check any new orders for the last 24 hours. The facility also had monthly checks in place to have the nursing staff check the most recent physician's orders [REDACTED]. With both checks in place, as well as the monthly review by the consultant pharmacist, the P & T report from the January quarter to the April quarter indicated an increase in medication errors. There was no documented evidence that any new interventions were put in place. The transcription errors as a concern was not addressed in the quarterly PI committee meetings minutes. Further review of the minutes of the meetings indicated that while there were references to medication errors, there was no evidence that the facility developed interventions through the PI process to correct the identified quality deficiencies. There was no further follow-up after the nursing inservices to determine if the nurses were then proficient in the areas reviewed. NJAC 8:39-33.1(a) 8:39-33.1(e)