Every finding on record at Lakeland Nursing & Rehab

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices for appropriate hand hygiene by a Licensed Practical Nurse (LPN) during a wound treatment observation, for 1 of 2 residents (Resident #31) reviewed for wound care. This deficient practice was evidenced by the following:On 4/22/26 at 8:09 AM, the surveyor observed an LPN perform wound care treatment to Resident #31 in their room. The Infection Preventionist (IP) and the Staff Educator were assisting with positioning of the resident in bed. During the wound treatment, the LPN cleansed the resident's wound bed area with a gauze applied with Dakin's solution as ordered, removed their gloves and then applied a new pair of gloves. The LPN did not perform hand hygiene in between changing gloves.The LPN cleansed Resident #31's wound in different areas five more times, changing to new gloves in between each cleanse without performing hand hygiene. The LPN packed the resident's wound with Dakin's solution gauze as ordered, doffed gloves, and applied new gloves without performing hand hygiene. The LPN took an island dressing to cover the resident's wound.On 4/22/26 at 10:43 AM, the surveyor interviewed the LPN about hand hygiene who stated hand hygiene should be performed during changing of gloves. The LPN acknowledged they did not perform hand hygiene in between glove change while cleansing the resident's wound.On 4/22/26 at 12:58 PM, the surveyor interviewed the Director of Nursing (DON) about hand hygiene expectation during glove change and wound treatment. The DON did not give a verbal response at this time. The surveyor informed the DON of the concern observed during wound treatment observation. The DON stated she would follow up with the LPN and then provide a response.On 4/22/26 at 1:20 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the DON of the hand hygiene concern observed during wound treatment. There was no response by the facility at this time.On 4/23/26 at 10:19 AM, the DON and LNHA met with survey team. The DON stated in-service education was initiated to nursing staff regarding hand hygiene. There was no additional information provided by the facilityThe surveyor reviewed the facility provided policy titled Handwashing/Hand Hygiene, last reviewed in September 2025. Under Policy Interpretation and Implementation revealed:7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . g. before handling clean or soiled dressings, gauze pads, etc. m. After removing gloves9. The use of gloves does not replace handwashing/hand hygiene.Under Procedure of the policy revealed:Applying and Removing GlovesPerform hand hygiene before applying non-sterile gloves. N.J.A.C. 8:39-19.4

COMPLAINT #NJ162233 Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for 1 of 1 resident reviewed, Resident #70. This deficient practice was evidenced by the following: On 7/22/24 at 11:02 AM, during initial tour, the surveyor observed Resident #70 resting in their bed with their eyes closed. The surveyor also observed the Registered Nurse (RN) in the room who stated that she assessed the resident's vital signs. On 7/22/24 at 11:32 AM, the surveyor reviewed the form that was provided by the facility titled, Reportable Event Record/Report for a Facility Reported Event (FRE) dated 3/9/23 which included the following: Today's date: 3/9/23 Date of Event: 3/7/23 Was This a Significant Event: Yes Was Significant Event Called in? Yes Date: 3/8/23 Time: 2:30 PM Type of Incident: Other, specify: Resident had a tuft fracture (a break at the tip of the fingers or toes) of the left thumb. The surveyor reviewed the medical record for Resident #70. A review of Resident #70's admission Record (an admission summary) indicated that the resident was admitted to the facility with diagnoses which included but not limited to Hypertension (elevated blood pressure), Metabolic Encephalopathy (a brain dysfunction [problem or fault] caused by problems with your metabolism, such as low glucose or high toxins), Cerebral Infarct (when an area of brain tissue dies due to inadequate blood supply and oxygen), and Age-related Osteoporosis (a condition that weakens bones and makes them more likely to break) without current pathological fracture (a broken bone that is caused by an underlying disease, rather than an injury). A review of Resident #70's Quarterly Minimum Data set (Q/MDS), an assessment tool used to facilitate the management of care, dated 1/10/23, reflected that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated that the interview with Resident #70 was not successful. Resident #70 had problems with short term and long-term memory. A review of Resident #70's progress notes (PN) dated 3/6/2023 at 08:42 AM, revealed that the resident was observed with bruising and some swelling to the left great thumb in the morning of 3/6/2024. The PN further documented that the Nurse Practitioner was notified who ordered to perform a left finger x-ray (painless test that captures images of the structures inside the body - particularly the bones). The x-ray was completed at on same day at 3:30 PM. A review of Resident #70's X-ray report dated 3/6/23 at 18:50 (6:50 PM) which revealed a result finding, minimally displaced tuft fracture of the distal (Situated away from the center of the body, or from the point of origin) thumb. A review of the resident's PN dated 3/7/2023 at 08:31 AM documented that x-ray result was faxed (a form of communication that involves scanning and transmitting printed documents from one machine to another) to MD (medical doctor). On 7/23/24 at 10:05 AM, the surveyor reviewed a form titled, Incident Investigation Sheet for Statements and Statement for investigation that was provided by Director of Nursing (DON). The form was utilized as an incident investigative form to document the statement of all the staff assigned to the resident in the last 72 hours prior to the incident. The Incident Investigation Sheet for Statements (IISS) form listed the names of the staff including nurses and Certified Nurse Assistants (CNAs), who provided the care to the resident prior to the incident beginning on 3/3/23 through 3/6/23 when the injury was identified. During the review of the IISS form, the surveyor noted that there were missing statements to complete the investigations for the incident on the following shifts: The surveyor did not see a CNA Statement for Investigation for 3/3/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/3/23 shift 11-7. The surveyor did not see a Nurse Statement for Investigation for 3/4/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/4/23 shift 11-7. The surveyor did not see a Nurse Statement for Investigation for 3/5/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/5/23 shift 11-7. On 7/23/24 at 12:53 PM, the surveyor interviewed the DON and the Licensed Practical Nurse / Regional Clinical Coordinator (LPN/ RCC) who stated that the facility usually goes back 2-3 days prior to the incident to gather the statements of the staff assigned to the resident. The surveyor notified the concern regarding the missing staff statements as part of the investigation process for the above-mentioned dates and shifts. The DON and LPN/RCC acknowledged that they could not find the missing statements mentioned above. The DON and LPN/RCC further stated that they were not employed by the facility at the time of the incident. On 7/25/24 at 11:14 AM, in the presence of second surveyor, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Business Office Manager (BOA) who stated, 7 staff members were a substantial number of staff who did not provide an explanation or statements. The LNHA further stated, providing statements were not an option. The LNHA acknowledged that the investigation of Resident #70's injury of the unknown origin was incomplete and should have included the complete staff interviews on all staff involved. No further information was provided. On 07/29/24 at 12:12 PM, the survey team met with the DON, LNHA and RCC. The LNHA could not provide any further information. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating was revised on 3/12/24, under Policy Statement included: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under Section Reporting Allegations to the Administrator and Authorities of Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating included: 7h.) interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. NJAC 8:39-4.1(a)(5)

COMPLAINT #NJ162233 Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for 1 of 1 resident reviewed, Resident #70. This deficient practice was evidenced by the following: On 7/22/24 at 11:02 AM, during initial tour, the surveyor observed Resident #70 resting in their bed with their eyes closed. The surveyor also observed the Registered Nurse (RN) in the room who stated that she assessed the resident's vital signs. On 7/22/24 at 11:32 AM, the surveyor reviewed the form that was provided by the facility titled, Reportable Event Record/Report for a Facility Reported Event (FRE) dated 3/9/23 which included the following: Today's date: 3/9/23 Date of Event: 3/7/23 Was This a Significant Event: Yes Was Significant Event Called in? Yes Date: 3/8/23 Time: 2:30 PM Type of Incident: Other, specify: Resident had a tuft fracture (a break at the tip of the fingers or toes) of the left thumb. The surveyor reviewed the medical record for Resident #70. A review of Resident #70's admission Record (an admission summary) indicated that the resident was admitted to the facility with diagnoses which included but not limited to Hypertension (elevated blood pressure), Metabolic Encephalopathy (a brain dysfunction [problem or fault] caused by problems with your metabolism, such as low glucose or high toxins), Cerebral Infarct (when an area of brain tissue dies due to inadequate blood supply and oxygen), and Age-related Osteoporosis (a condition that weakens bones and makes them more likely to break) without current pathological fracture (a broken bone that is caused by an underlying disease, rather than an injury). A review of Resident #70's Quarterly Minimum Data set (Q/MDS), an assessment tool used to facilitate the management of care, dated 1/10/23, reflected that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated that the interview with Resident #70 was not successful. Resident #70 had problems with short term and long-term memory. A review of Resident #70's progress notes (PN) dated 3/6/2023 at 08:42 AM, revealed that the resident was observed with bruising and some swelling to the left great thumb in the morning of 3/6/2024. The PN further documented that the Nurse Practitioner was notified who ordered to perform a left finger x-ray (painless test that captures images of the structures inside the body - particularly the bones). The x-ray was completed at on same day at 3:30 PM. A review of Resident #70's X-ray report dated 3/6/23 at 18:50 (6:50 PM) which revealed a result finding, minimally displaced tuft fracture of the distal (Situated away from the center of the body, or from the point of origin) thumb. A review of the resident's PN dated 3/7/2023 at 08:31 AM documented that x-ray result was faxed (a form of communication that involves scanning and transmitting printed documents from one machine to another) to MD (medical doctor). On 7/23/24 at 10:05 AM, the surveyor reviewed a form titled, Incident Investigation Sheet for Statements and Statement for investigation that was provided by Director of Nursing (DON). The form was utilized as an incident investigative form to document the statement of all the staff assigned to the resident in the last 72 hours prior to the incident. The Incident Investigation Sheet for Statements (IISS) form listed the names of the staff including nurses and Certified Nurse Assistants (CNAs), who provided the care to the resident prior to the incident beginning on 3/3/23 through 3/6/23 when the injury was identified. During the review of the IISS form, the surveyor noted that there were missing statements to complete the investigations for the incident on the following shifts: The surveyor did not see a CNA Statement for Investigation for 3/3/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/3/23 shift 11-7. The surveyor did not see a Nurse Statement for Investigation for 3/4/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/4/23 shift 11-7. The surveyor did not see a Nurse Statement for Investigation for 3/5/23 shift 3-11. The surveyor did not see a CNA Statement for Investigation for 3/5/23 shift 11-7. On 7/23/24 at 12:53 PM, the surveyor interviewed the DON and the Licensed Practical Nurse / Regional Clinical Coordinator (LPN/ RCC) who stated that the facility usually goes back 2-3 days prior to the incident to gather the statements of the staff assigned to the resident. The surveyor notified the concern regarding the missing staff statements as part of the investigation process for the above-mentioned dates and shifts. The DON and LPN/RCC acknowledged that they could not find the missing statements mentioned above. The DON and LPN/RCC further stated that they were not employed by the facility at the time of the incident. On 7/25/24 at 11:14 AM, in the presence of second surveyor, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Business Office Manager (BOA) who stated, 7 staff members were a substantial number of staff who did not provide an explanation or statements. The LNHA further stated, providing statements were not an option. The LNHA acknowledged that the investigation of Resident #70's injury of the unknown origin was incomplete and should have included the complete staff interviews on all staff involved. No further information was provided. On 07/29/24 at 12:12 PM, the survey team met with the DON, LNHA and RCC. The LNHA could not provide any further information. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating was revised on 3/12/24, under Policy Statement included: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under Section Reporting Allegations to the Administrator and Authorities of Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating included: 7h.) interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. NJAC 8:39-4.1(a)(5)

Complaint #: NJ00165369 Based on interviews and review of medical records (MRs) and other facility documentation on 9/13/23, 9/14/23, and 9/19/23, it was determined that facility failed to thoroughly investigate an alleged staff-to-resident verbal abuse allegation and to follow facility policy titled Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention for 1 of 3 residents (Resident #2). This deficient practice is evidenced by the following: A review of the statement written by the Certified Nursing Assistant (CNA #1) to the Facility's Regional Human Resources (RHR) via email, dated 9/11/23 at 12:51 a.m., revealed that CNA #1 heard and seen [CNA #2] abuse, scream, and disrespect patients and their Families on XX unit. The statement further revealed that CNA #1 reported the aforementioned incident to the Licensed Practical Nurse (LPN #1). According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to; Alzheimer's Disease, Hemiplegia and Hemiparesis. A Minimum Data Set (MDS), an assessment tool, dated 9/7/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated his/her cognition was severely impaired and the resident needed assistance with activities of daily living (ADLs). A Care Plan (CP), initiated on 12/15/21, included that the resident had an increased in forgetfulness as well as difficulty with problem solving and trouble sequencing, had diagnosis of Alzheimer's Dementia. During an interview with the surveyor on 9/13/23 at 7:18 a.m. and 9/14/23 at 8:30 a.m., CNA #1 confirmed what was written on the statement. CNA #1 stated that she verbally reported an allegation of verbal abuse to RHR and LPN #1 (unable to recall date and time). According to CNA #1 she witnessed CNA #2 being rude, screamed at [Resident #2] and family members, when [CNA #2] talks to residents, she snapped and would say, 'you have to wait, stop, I'm coming to you when I come.' During an interview with the RHR on 9/13/23 at 9:43 a.m. and 1:38 p.m., the RHR confirmed receiving the 2 statements (statement #1 and statement #2) via email from CNA #1 (unable to recall time and date) involving CNA #1 and CNA #2. RHR admitted that she read the statements, however, she did not report the allegation of abuse (Statement #2) to the Administrator and the Director of Nursing (DON). The RHR stated that when she received the email and read it, the RHR didn't follow-up the allegation of abuse because it was a personality conflict among staff. The RHR further added that the letter that she received was attention seeking, clearly its personality conflict among staff and not an abuse . During an interview with the Assistance DON (ADON), DON, and Administrator on 9/13/23 at 11:36 a.m. and 2:30 p.m., the Administrator stated that he received the email on 9/11/23, however, he only read statement #1 not realizing there was statement #2 until 9/12/23. The Administrator stated that the incident was not investigated and reported to the New Jersey Department of Health (NJDOH) because he was not aware of statement #2. The Administrator added if there was an allegation of abuse, the facility would immediately investigate and reported to NJDOH within 2 hours. The administrator also stated that the statement #1 and statement #2 involving CNA #1, CNA #2, and CNA #3 was not considered an allegation of abuse. During the survey on 9/13/23, 9/14/23, 9/19/23, CNA #2 was not available for interview. CNA #2 last worked on 9/9/23 and will not be returning to work until 1/2024. Review of a facility policy titled Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention, dated 8/2023, indicated .The purpose is to assure that the facility is doing all that is within its control to prevent occurrences .Prevention .Reporting/Response .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will .2. Have evidence that all alleged violations are thoroughly investigated . NJAC 8:39-9.4 (f)

C #: NJ00160399 and NJ00167145 Based on interviews, medical record review, and review of other pertinent facility documents on 9/13/23, 9/14/23, and 9/19/23, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to the facility protocol for 3 of 4 residents (Resident #2, Resident #3, and Resident #4) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the facility Admission Record (AR), Resident #2 was admitted on [DATE], with diagnosis that included but were not limited to: Hemiplegia and Hemiparesis, and Alzheimer's Disease. The Minimum Data Set (MDS), an assessment tool, dated 9/7/23, revealed a Brief Interview of Mental Status (BIMS) of 3 which indicated the resident's cognition was severely impaired and the resident needed assistance with activities of daily living (ADLs). Review of Resident #2's DSR (ADL Record) and the progress notes (PN) for the month of 8/2023 and 9/2023, lack any documentation to indicate that the care for dressing, personal hygiene, toileting, transfer, and eating was provided and/or the resident refused care on the following dates and shifts. 7:00 a.m.-3:00 p.m. shift on 8/1/23, 8/10/23, 8/11/23, 8/18/23, 8/17/23, 8/25/23, 8/28/23, and 8/31/23. 3:00 p.m.-11:00 p.m. shift on 8/1/23, 8/4/23, 8/7/23, 8/10/23 to 8/12/23, 8/15/23, 8/18/23, and 8/21/23. Toileting: 11:00 p.m.-7:00 a.m. shift on 8/1/23 to 8/423, 8/11/23 to 8/13/23, 8/18/23 to 8/21/23, 8/23/23 to 8/25/23. 2. According to the facility AR, Resident #3 was admitted on [DATE], with diagnosis that included but were not limited to: Need for Assistance with Persona Care. The MDS, dated [DATE], revealed a BIMS of 15 which indicated the resident's cognition was intact and the resident needed assistance with ADLs. Review of Resident #3's DSR and the PN for the month of 8/2023 and 9/2023, lack any documentation to indicate that the care for dressing, personal hygiene, toileting, transfer, and eating was provided and/or the resident refused care on the following dates and shifts. 7:00 a.m.-3:00 p.m. shift on 8/19/23, 9/2/23, and 9/7/23. 3:00 p.m.-11:00 p.m. shift on 8/26/23, 8/28/23, 9/6/23, and 9/7/23. 5/7/23. 11:00 p.m.-7:00 a.m shift (exclude eating and toileting) on 8/1/23 to 8/31/23, 9/1/23 to 9/12/23. Toileting: 11:00 p.m.-7:00 a.m. shift on 8/20/23, 8/21/23, and 9/3/23. 3. According to the facility AR, Resident #4 was admitted on [DATE], with diagnoses that included but was not limited to: Muscle Weakness, repeated Falls, and Cataract. The MDS, dated [DATE], revealed a BIMS of 3 which indicated the resident's cognition was severely impaired and the resident needed extensive assistance with ADLs. Review of Resident #4's DSR and the PN for the month of 8/2023 and 9/2023, lack any documentation to indicate that the care for dressing, personal hygiene, toileting, transfer, and eating was provided and/or the resident refused care on the following dates and shifts. 7:00 a.m.-3:00 p.m. shift on 8/2/23, 8/4/23 to 8/10/23, 8/13/23, 8/14/23, 8/16/23 to 8/18/23, 8/20/23, 8/21/23, 8/25/23. 3:00 p.m.-11:00 p.m. shift on 8/1/23, 8/7/23, 8/8/23, 8/11/23, 8/14/23, 8/25/23, 8/28/23. 11:00 p.m.-7:00 a.m. shift (exclude eating and toileting) on 8/1/23 to 8/31/23, 9/1/23 to 9/12/23. Toileting: 11:00 p.m.-7:00 a.m. shift on 8/2/23, 8/9/23, 8/13/23, 8/16/23, 8/18/23, 8/23/23, 8/29/23, 9/3/23, and 9/7/23. During an interview with the surveyor on 9/12/23 at 11:54 a.m., CNA #3 stated that CNAs are responsible for documenting the ADL care provided into the Point of Care (POC), is a mobile-enabled app that runs on wall-mounted kiosks or mobile devices that enables care staff to document activities of daily living at or near the point of care to help improve accuracy and timeliness of documentation. CNA #1 further stated that they would document even if the care was not provided due to refusal. She explained that the documentation must be completed in the resident's DSR by the end of each shift to show that the care was provided to the residents. During an interview with the surveyor on 9/13/23 at 8:14 a.m., Licensed Practical Nurse (LPN #1) stated that the Certified Nursing Assistants (CNAs) were expected to document ADL care provided to the resident by the end of the shift in the DSR. He explained that the care were provided. During an interview with the surveyor on 9/14/23, the residents confirmed that the CNAs were providing care and had no care issues. During an interview with the surveyor on 9/13/23 at 1:02 p.m., the Director of Nursing (DON) and ADON stated that the CNAs were expected to document the care provided to the residents in the DSR at the end of the shift. NJAC 8:39-35.2(d)(9)

Complaint #: NJ00165369 Based on interviews, and record review, as well as review of pertinent facility documents on 9/13/23, 9/14/23, and 9/19/23, it was determined that the facility failed to report an allegation of a resident-to-resident physical and verbal abuse to the New Jersey Department of Health (NJDOH) and to follow the facility policy Abuse Neglect Exploitation Mistreatment and missappropriatin of Property Prevention for 1 of 3 residents (Resident #7) reviewed for grievance. This deficient practice is evidenced by the following: According to the Admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to; Dementia, Post Traumatic Stress Disorder, and Obsessive Compulsive Disorder. A Minimum Data Set (MDS), an assessment tool, dated 9/7/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated his/her cognition was intact and the resident needed assistance with activities of daily living (ADLs). Review of the Concerns/Grievance Form (CGF), dated 12/12/22 for Resident #7. The CGF indicated see the attached written compliant from resident. The CGF also indicated that the letter was forwarder to Administrator and Director of Nursing (DON). Furthermore, the CGF, under ACTION TAKEN indicated that the Social Worker (SW) had asked resident on numerous occasions if [she/he] would like a room change which [she/he] declined. The CFG indicated that the situation had been resolved. Included in the CFG was a written letter from Resident #7, dated 12/12/22. Resident #7 indicated on the letter that she/he felt that she/he was being physically and verbally abused by her/his roommate (Resident #9). The letter further indicated Resident #9 would call Resident #7 an animal, live like an animal, and ugly. Resident #7 also indicated on the letter that these words were acts of verbal and emotional abuse. The letter revealed that Resident #9 physically abused Resident #7, Resident #9 would use her/his walker and used as a weapon. Resident #7 explained that Resident #9 takes [her/his] walker and [NAME] it into the chair. [Resident #9] repeats this action 4 or 5 times in a row, several times a day - EVERYDAY. This has been going on for at least two months .[she/he] doing so violently .I'm emotionally drained by the verbal and non-verbal abuse . During an interview with the surveyor on 9/19/23, 1:36 p.m., the Social Worker (SW) confirmed receiving the letter from Resident #7 on 12/12/22. The SW stated the letter was not thoroughly read; however, she asked the Resident to summarize the letter. The SW added the letter was forwarded to the Administrator and Director of Nursing (DON). She further stated that she did not report the allegation of abuse to the NJDOH. During an interview with the DON and Administrator on 9/19/23 at 12:15 p.m. and 2:30 p.m., the Administrator stated that he received and discussed the letter with Resident #7's after 12/12/22 (unable to recall exact date and time). He further stated that the letter was unreadable and discussed the content of the letter directly to the Resident. The Administrator explained that during the interview with the Resident, she/he did not verbalize of the abovementioned allegation of physical and emotional abuse and was not reported to the NJDOH. Review of a facility policy titled Abuse Neglect Exploitation Mistreatment and misappropriation of Property Prevention, dated 8/2023, indicated .The purpose is to assure that the facility is doing all that is within its control to prevent occurrences .Reporting/Response .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will 1. Ensure that all alleged violations involving abuse, neglect .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .to other officials (including the State Survey Agency .in accordance with State law through established procedures. 2. Have evidence that all alleged violations are thoroughly investigated . NJAC 8:39-9.4 (f)

Based on observation, interview, record review, and policy review, the facility failed to ensure resident's nutrition needs were met for one of nine residents (Resident (R)103) reviewed for nutrition. The facility failed to reconcile discrepancies between facility weights, reflecting stable weight, and hospital weights, reflecting significant weight loss. R103 was weighed during the survey and weighed 126 pounds; the most recent facility weight two weeks earlier was 170.6 pounds. Due in part to the failure to obtain accurate weights, review the hospitalization documentation in the resident's record, and physically/clinically assess the resident, R103's tube feeding regimen was not increased to address weight loss, severe protein malnutrition, and a worsening sacral pressure ulcer. Findings include: 1. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab, revealed R103 was admitted to the facility on [DATE] with diagnoses including sepsis, hypoglycemia (low blood sugar), acute kidney failure, heart failure, acute respiratory failure, leukemia, protein calorie malnutrition, and type two diabetes mellitus. Review of the hospital Physician Progress Note dated 07/06/22 (two days prior to admission) in the EMR under the Misc tab, revealed R103 was cachectic [physical wasting with loss of weight and muscle mass] and had a low albumin [measure of visceral protein stores] level of 2.1. The Progress Note indicated, His nutrition status is very poor, follow nutrition consult recommendations to improve status . sacral decubitus ulcer stage 3. In addition, review of the hospital Infectious Disease Inpatient Note dated 07/07/22, in the EMR under the Misc tab, revealed R103 had ulcers in the back of his mouth. Review of a Nurse's Note dated 07/13/22 at 7:35 AM, in the EMR under the Progress Notes tab revealed R103 was transferred to the emergency room due to hypoglycemia. Review of the hospital History and Physical dated 07/13/22 and in the EMR under the Misc tab, revealed R103 was sent to the hospital due to being minimally responsive and had an initial glucose of 52. His oxygen saturations were in the upper 80s, and he had yellow sputum. His sodium level was elevated at 149. R103 had a 17 day stay, 07/13/22 through 07/30/22, in the hospital and was diagnosed with a pneumonia with severe sepsis. A pureed diet with thickened beverages was ordered. The resident was diagnosed with severe protein calorie malnutrition. Review of the hospital Physician's Note dated 07/25/22 and in the EMR under the Misc tab, revealed R103 had dysphagia (impaired swallowing), severe protein malnutrition and would continue with pureed diet and thick liquids. R103 had poor intake of his pureed diet and reported having no appetite. Review of the hospital Vitals and Labs dated 07/18/22 - 07/25/22, in the EMR under the Misc tab, revealed R103 weighed: -141 pounds on 07/24/22 -138 pounds on 07/25/22. R103 was hospitalized on [DATE] and returned to the facility on [DATE]. Review of the hospital History and Physical dated 08/02/22 revealed R103's chief complaint was a low hemoglobin lab of 5.5. The History and Physical revealed R103 had a percutaneous endoscopic gastrostomy (PEG) feeding tube recently placed (07/28/22). Review of the hospital RD Progress Notes dated 08/02/22 and in the EMR under the Misc tab, revealed R103 had severe protein calorie malnutrition with loss of muscle mass, loss of subcutaneous body fat, insufficient energy intake and weight loss. R103 had lost 15% in seven - eight months. R103's energy intake was less than or equal to 50% of his estimated energy requirements for equal to or greater than a month. Increased nutrient needs were required for wound healing. R103's weight records documented in the progress note were: -176 pounds (lbs) on 12/13/21 -152 pounds on 07/30/22 -150 pounds on 08/01/22. Review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/22 in the EMR under the MDS tab, revealed R103 was unimpaired in cognition with a Brief Interview for Mental Status score (BIMS) of 15 (score of 13 - 15 indicates cognition is intact). R103 was 68 (5'8) tall and weighed 171 pounds according to the facility's weights. R103 was not coded as having experienced a significant weight loss in the last month or six months. R103 received 51% or more of his nutrition via a feeding tube. Review of the facility's Weight Summary from 07/08/22 - 09/01/22 in the EMR under the Vitals tab revealed R103's weights were: 07/08/22 169.0 lbs 07/09/22 169.0 lbs 07/30/22 173.0 lbs 08/03/22 140.0 lbs (this weight was noted as being an error on 08/04/22; however, there was no evidence of an immediate reweigh being obtained or a weight being obtained on 08/04/22 the day after readmission in accordance with facility policy). 08/06/22 172.0 lbs 08/13/22 170.6 lbs Review of the Order Summary Report dated August 2022 in the EMR and under the Orders tab, revealed an order for Weekly weight x [for] 4 weeks. The order was dated 08/06/22. As of the survey on 09/01/22; R103 had not been weighed at the weekly interval following his most recent weight on 08/13/22. He would have been due for a weight on 08/20/22 and 08/27/22. As of the survey (09/01/22), R103 had not been weighed since 08/13/22. A weight was requested. During an observation on 08/31/22 at 10:58 AM, Certified Nurse Assistant (CNA) 4 weighed R103 using the Hoyer lift. CNA4 stated R103 weighed 126 pounds, which was verified by the surveyor. R103 was reweighed a second time on 08/31/22 and again his weight was 126 pounds. During an interview on 08/31/22 at 1:23 PM, CNA4 verbally confirmed R103's weight was 126 pounds. CNA4 stated she had taken R103's weight before but could not remember when. She stated she did not know why there was such a huge disparity between his current weight of 126 pounds and last recorded weight of 170.6 pounds (two weeks earlier). Review of the RD Nutrition Evaluation dated 07/11/22 and in the EMR under the Assessment tab, revealed R103's nutritional requirements were: 1925-2,310 calories and milliliters of fluid per day. R103 required 100-116 grams of protein per day. R103 ate 25% of meals and was noted with a severe decrease in food intake. R103 had a low albumin (measure of protein level) of 2.1 and an unstageable pressure ulcer to the sacrum, a left buttock stage II pressure ulcer, a left ischial stage II pressure ulcer, a right shin pressure ulcer, and a right elbow open area. The resident's past medical history included: leukemia, acute kidney failure, cellulitis of right lower limb, hypertension (HTN), acute respiratory failure with hypoxia. The resident was prescribed a regular diet, ground texture, honey thick liquids. The resident received no supplements. The resident's height was 68 inches tall, and his body mass index (BMI) was 25.7 [overweight per RD assessment]. The resident's current body weight was 169 pounds. His weight was noted to be stable. The resident's intake was not great, and he was drinking more than eating, and because of this the resident was receptive to add Ensure to his tray to deter any weight loss. The resident required limited assistance with meals. The resident was noted to be at risk for malnutrition due to need for altered consistency diet and wounds . Recommendations included: weekly weights x 4 weeks, Ensure 8 oz three times a day, and Proheal Critical Care 30 milliliters (ml) three times a day. Review of the Medication Administration Record (MAR) for July 2022 in the EMR under the Orders tab revealed the recommended interventions noted above (Ensure three times a day was administered on 07/11/22; Liquid Protein Proheal 30 ml three times a day was administered on 07/12/22 and 07/13/22) were implemented for no more than two days, until R103 was hospitalized on [DATE]. Review of the Nutrition Evaluation dated 08/05/22 and in the EMR under the Assessment tab, revealed R103 was malnourished. His admission weight dated 08/03/22 was 172 pounds. R103 was documented with a stable weight. There was no evidence the Registered Dietitian reviewed the hospital documentation that showed the resident's hospital weights were 152 pounds on 07/30/22, 141 pounds on 07/24/22, and 150 pounds on 08/01/22. The Nutrition Evaluation revealed a gastrostomy feeding tube had been inserted while the resident was in the hospital, and he was tolerating it well without any gastrointestinal (GI) distress or discomfort. The resident received a pureed diet with thickened liquids in addition to nutrition provided via the feeding tube. R103 was eating 25% of meals. He received Jevity tube feeding formula 1.2 at 70 ml/hour for 24 hours a day which provided 2016 calories and 93 grams (gm) protein. R103 was noted to have a low albumin lab of 2.7. R103 continued to have pressure ulcers and was prescribed a multi-vitamin and zinc sulfate. R103 was noted with increased calorie and protein needs. R103's calorie needs were 1955-2346 per day and his protein needs were 94-117 gm per day. The RD recommended adjusting the tube feeding to Jevity 1.2 at 75 ml hour for 20 hours, which provided 1800 kcal, and 83 grams protein. A recommendation for Prostat 30 ml twice daily was made which provided an additional 200 calories and 30 grams protein to assist with wound healing. One of the nutrition goals was for the resident to maintain weight within 5% of his current weight (172 pounds). There were no additional nutritional evaluations or notes until after the survey started at which time the resident's weight of 126 pounds was obtained. Review of the Order Summary Report dated August 2022 in the EMR and under the Orders tab, revealed current tube feeding orders as follows: Glucerna 1.2 liquid via [percutaneous endoscopic gastrointestinal (PEG)] to run at 75 ml/hour via pump. Total volume to be infused:1500 ml/20hrs. Up at 4:00 pm and down when TV [total volume] is infused. Provides 1800 Kcal [calories], 90 grams protein, 1207 ml water, initiated on 08/22/22. In addition, R103 received a water flush of 250 ml of water every shift equaling 750 ml free water/day and a total of 1,957ml/of water per day. Review of the Order Summary Report dated August 2022 in the EMR and under the Orders tab, revealed liquid protein supplement at 30 ml twice a day was initiated on 08/09/22. Review of the meal intake Follow Up Question Report for July 2022 and August 2022 and provided by the facility revealed R103 ate two meals in the five-day period from admission on 07/08/22 until he was hospitalized on [DATE]. For the month of August (from 08/01/22 - 08/31/22 noting he was hospitalized for two days) R103 was documented with meal intake on five days as follows: four meals with intake of 0-25% and one meal with intake of 51-75%. Review of the wound care Follow-up Progress Notes dated 08/10/22 and in the EMR under the Assessment tab, revealed R103 was being seen by a wound care Nurse Practitioner starting on this date, and was seen weekly thereafter. The stage three sacrum pressure ulcer was 7.1 centimeters (cm) in length by (x) 5.5 cm in width x 1.1 cm in depth. The total square size in centimeters was 39.05. Review of the wound care Follow-up Progress Notes dated 08/31/22 and in the EMR under the Assessment tab, revealed R103's stage three sacral pressure ulcer was 8.9 cm in length x 7.1 cm in width x 1.4 cm in depth. The total square size in centimeters was 63.19. R103's pressure ulcer got larger and deeper based on the wound progress notes. Review of the Care Plan initiated on 07/11/22 in the EMR and under the Care Plan tab, revealed: The resident has a nutritional problem or potential nutritional problem r/t [related to] multiple wounds, risk of weight changes and nutritional deficiencies. readmitted post peg tube insertion 7/28/2022; Date Initiated: 07/11/2022 - [R103] skin will progress towards healing through review date. - [R103] will remain on the least restrictive diet x 90 days - [R103] will maintain adequate hydration and nutrition via peg tube x 90 days - Administer medications as ordered. Monitor/Document for side effects and effectiveness. - Continue peg feeding & diet (puree with NTL [nectar thick liquids]) - Monitor/document/report to MD [Medical Doctor] PRN [as needed] for s/sx [signs and symptoms] of dysphagia [impaired swallowing}: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. - Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. - Offer ice chips for swallow stimulation - Provide and serve supplements as ordered - Provide enteral feeding as ordered - RD to evaluate and make diet change recommendations PRN. During an observation on 08/29/22 at 10:44 AM, R103 and family member (F)103 were in R103's room. R103 was lying in bed while his tube feeding formula of Glucerna 1.2 was being administered. The resident was wearing a hospital gown and was thin with decreased muscle mass and a lack of visible fat stores noted. R103's facial structure was sunken, and his collar bones protruded from beneath the top edge of the hospital gown. During an interview on 09/01/22 at 10:34 AM, F103 stated she came daily and stayed with R103 from 10:00 AM until about 5:00 PM - 6:00 PM and she had not seen R103 weighed prior to today. F103 stated she observed R103 being weighed and his weight of 126 pounds earlier that day. F103 stated, He is not 170 pounds; anyone could see that. F103 stated it had been quite a while since R103 weighed 170 pounds, verifying a history of weight loss. F103 stated R103 would not eat the pureed diet that was served to him even though staff brought it to him every meal. R103 was in the room and verified his weight of 126 pounds today. R103 had a soft voice, and it was difficult to understand him. During an interview on 08/30/22 at 1:23 PM, Licensed Practical Nurse (LPN)1 and LPN5 were interviewed. They stated R103 did not eat the pureed diet he was served. They stated R103's pressure ulcer became infected, and he had a catheter inserted to help with wound healing as R103 was incontinent. They stated R103 had no tolerance issues with the tube feeding. During an interview on 08/30/22 at 2:37 PM, Certified Nursing Assistant (CNA)4 stated R103 was served a pureed diet; however, he did not eat it. During an interview on 08/31/22 at 11:46 AM, the RD and Regional RD were interviewed and stated R103 was weighed with a Hoyer lift. The RD stated the facility weights indicated R103 had experienced a small weight gain. The RD stated nursing was responsible for obtaining the weights and she had not questioned the accuracy of his weights being in the 170s. The RD stated the resident was offered a pureed diet in addition to the tube feeding; she stated she was not aware he did not eat it. The RD reviewed the meal intake records in the computer and verified intake of 0-25% of the pureed diet when it was documented. The RD and Regional RD stated the current tube feeding regimen was meeting R103's nutritional needs. They stated R103's calorie needs from the most recent assessment dated [DATE] were based on his weight at that time and he required 1955 -2346 calories. The RD verified R103's current tube feeding regiment provided 1800 calories, which was less than his assessed needs; however, they stated he also received 30 ml twice daily of the protein supplement providing an additional 200 calories. During a follow up interview on 08/31/22 at approximately 1:30 PM, the RD and Regional RD stated they were aware of R103's weight of 126 pounds. The RD stated she would assess R103's tube feeding regimen with weight loss and a lower body weight (126 pounds versus 170 pounds) because this affected his nutrient needs. The RD stated, We do base the nutrition assessment on his weight. The RD verified if the resident had been losing weight, the tube feeding regimen was not sufficient to meet his needs and would need to be increased. The RD stated she had observed the resident and stated he was not overweight, and she did realize the facility's weights in the 170s were incorrect. The RD stated she depended on the nurses to document accurate weights and verified she had not reviewed the hospital weights when completing her nutrition assessment on 08/05/22. During an interview on 09/01/22 3:40 PM, Registered Nurse (RN)2 stated she was the nurse who crossed out the weight of 140 pounds (obtained on 08/03/22) because she thought it was a mistake. RN2 stated she usually asked the CNAs to obtain a reweigh if a weight was suspicious. RN2 stated she may have forgotten to have the CNAs reweigh him or to follow up. RN2 stated she did not observe the CNAs obtaining the weights. RN2 stated she should have asked staff to reweigh the resident. RN2 stated R103 was thin but she was not sure if he looked like he had lost weight. A call was made to R103's Physician on 09/01/22 at 11:37 AM and a message was left with the receptionist to ask the Physician to return the surveyor's call. R103's Physician did not return the call. During an interview on 09/01/22 at 4:12 PM, the Director of Nursing (DON) stated whenever there was a weight discrepancy, the RD looked at it and requested a reweigh. The DON stated she was not sure why a reweigh was not done after the weight of 140 pounds was obtained. The DON stated R103 was not eating anything in July 2022, and he was sent to the hospital, and he returned with a feeding tube. The DON stated the only thing R103 ate was ice cream. The DON stated R103 was weighed with the Hoyer lift. When a weight discrepancy was noted, a reweigh should be done. The DON stated it was the RD's responsibility to request a reweigh and she was not sure why this was not done. The DON stated the RD should have looked at the hospital weights. The DON verified when she had observed the resident, he was thin. She was not aware his weights had been recorded in the 170s. The DON stated R103 was weighed twice yesterday to make sure the weight of 126 was correct, because it was a big jump from 170. The DON stated the CNAs obtained the weights, but the RD oversaw the process. The DON stated if a weight were missing or a reweigh was needed, she would make sure the nurse does the weight, but this had not been reported to her. Review of the Weight Management policy dated 02/01/22 and provided by the facility revealed all residents admitted to the facility would be weighed on the day of admission, the day after admission and then weekly for four weeks. The policy indicated, A re-weight will be obtained for any weight change of +/- (3) lbs [pounds] from the previous weight unless other parameters have been ordered by the physician. All re-weights will be obtained immediately. The re-weight process will be visualized by a license nurse. Review of the undated Enteral Feeding policy, provided by the facility revealed, The Dietitian will be notified of the tube feeding orders and assess nutrition/hydration needs of the resident. Based on the outcome of assessment the dietitian will make recommendations for tube feeding type, rate, volume, and water flushes. NJAC 8:39-17.1(c) NJAC 8:39-17.2(d) NJAC 8:39-27.2(e)

20402 28154 32513 Based on observation, record review, and staff and resident interviews, the facility failed to develop a comprehensive plan of care directing measurable goals and interventions for five residents in a total sample of 25 (Resident (R) 3, R32, R43, R101, and R103). The facility failed to develop a care plan for pain for R3, resident choices for R101, side rails for R32, behaviors for R43, and nutrition for R103. These failures placed the residents at risk for unmet care needs and a diminished quality of life. Findings included: 1. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses that included dementia, stroke, and heart failure. Review of the current Order Summary located in the Orders tab of the EMR revealed R3 was prescribed Tramadol [a pain medication] 50 mg [milligram] every six hours for moderate-severe pain on 07/26/22. Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/24/22 revealed, R3 had a Brief Interview of Mental Status (BIMS) of 03 out of 15 which indicated she was severely impaired in cognition for daily decision-making, had no pain indicators and received an opioid medication daily during the assessment period. Review of the EMR showed a care plan for pain had not been developed with measurable goals or resident-specific interventions. During an initial interview on 08/29/22 at 11:37 AM, R3 was lying in bed, softly crying. She stated that her left leg hurt. Licensed Practical Nurse (LPN) 2 was informed of the resident's pain and stated, She is scheduled to receive Tramadol at 12:00 but I will give it to her now. During an interview on 09/01/22 at 8:30 AM, LPN3 was asked about R3's pain and how it was managed. LPN3 stated the Tramadol used to be as needed, however we now have a standing order for the Tramadol. The pain is located in her left leg and foot and at times both legs. LPN3 stated R3 had peripheral vascular disease and venous insufficiency. LPN 3 was asked if there was a care plan for R3's pain and current interventions. LPN3 confirmed that a Care Plan for pain was not developed for R3's pain. 2. Review of R32's printed Admission Record from the EMR Profile tab showed an admitted [DATE], and a readmitted [DATE], with medical diagnoses that included cerebral palsy, obesity, chronic osteomyelitis, sacral pressure ulcer, difficulty in walking, and fall history. Observation on 08/29/22 at 2:26 PM showed R32's bed had bilateral upper side rails, and R32 was sitting up at the bedside using the side rails for mobility. On 08/30/22 at 3:03 PM, R32's bed had bilateral upper side rails. Review of R32's hard (paper) chart showed an .Assist Bar/Side Rail assessment completed on 09/20/21 with a signed informed consent (the risks and benefits of side rails) dated 03/30/22. The consent form stated: POTENTIAL NEGATIVE OUTCOMES: I understand that the use of side rail(s) may involve risks such as: getting caught in the rails, getting caught between the rail and the mattress, strangulation, hitting against the rail(s) causing skin tears and/or bruising and crawling over the top of a rail risking a fall from a higher level with a risk for greater injury or death. Review of R32's care plan, from the EMR Care Plan tab, showed, in pertinent parts: Focus: [R32's name] has an ADL [activities of daily living] Self Care Performance Deficit secondary to pain, impaired mobility Date Initiated: 05/18/2016 Revision on: 12/22/2021. Focus: [R32's name] is at risk for falls r/t [related to] history of multiple falls, impaired balance, use of psychotropic medications & pain medications, poor safety awareness, . Date Initiated: 10/03/2014 Revision on: 09/27/2021. Interventions: Assist with bed mobility, transfers, toileting, dressing, hygiene, bathing Date Initiated: 09/27/2021. Further review of R32's care plan did not address the use of side rails with inherent risks. During an interview on 08/31/22 at 4:48 PM, the Director of Nursing (DON) stated an expectation that side rails would be care planned under ADLs. 3. Review of R43's printed Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included frontotemporal dementia, adjustment disorder, and bipolar disorder. Review of R43's care plan from the EMR Care Plan tab showed: Focus: [R43's name] is currently on Antipsychotic & Antidepressant medication, as well as Depakote for mood/behavior S/S [signs/symptoms] of depression noted- states he wants to be home in his environment DX[diagnosis]: Frontotemporal Dementia, Depression, Bipolar D/O, inappropriate mood/behaviors [R43's name] makes sexual innuendos towards nursing staff Continues accusatory & sexually inappropriate behavior towards staff, grabbing staff breast and private areas, touching himself inappropriately. Date Initiated: 03/25/2022 Revision on: 08/29/2022 Goal: [R43's name] will have fewer behaviors weekly x 90 days Date Initiated: 03/25/2022 Revision on: 07/05/2022 Target Date: 10/01/2022 -[R43's name] will fewer s/s of depression x 90 days Date Initiated: 03/25/2022 Revision on: 07/05/2022 Target Date: 10/01/2022 . Further review of the care plan did not address how many behaviors and/or signs and symptoms of depression R43 experienced in the 90 days prior to the revision on 07/05/22 to have a baseline to measure if the goal had been attained. During an interview on 09/01/22 at 4:10 PM the DON confirmed the care plan goals were not measurable and [the facility] could tighten up on the behavior and side effect monitoring. 4. During observation and interview on 08/28/22 at 11:22 AM, R101 was observed walking independently from his room to look out a window on the first floor. During interview, R101 stated, I want to go walking. I love going outside and getting fresh air. I used to go outside all the time and walk the neighborhood, talk to people, go down to the police station, the stop shop car dealer place, and just walk the neighborhood. R101 stated, I'm able to walk independently. I feel alive when I'm able to go for walks. Now, I feel depressed because the new administrator says I can't go outside. At this time, R101 stated, There has been a new administrator that says I can't go for my walks anymore. R101 stated, I used to sign myself in/out when I came and when I left. They tell me now if I want to go outside, I have to have someone with me. R101 stated, We've had meetings about this in the past, but I feel they don't want to help me. During an observation and interview on 09/01/22 at 7:50 AM, R101 was observed walking around independently. He was observed well dressed in tennis shoes, socks, shorts, and a t-shirt. During interview R101 stated, I asked the Administrator on an update about being able to go for my walks outside. I guess they don't feel comfortable with me walking out there. I would like to go for my walks on my own. I say hi to people. I would sign myself in/out. As soon as I eat my breakfast, I would like to take an hour, take my time, say hi to people and go for a walk. It makes feel excited, happier, and I feel better just to get fresh air. Review of an undated Profile located in R101's electronic medical record (EMR) under the Profile tab revealed R101 was his own responsible party. Review of R101's medical diagnosis located in R101's EMR under the Med (medical) Diag (diagnosis) tab indicated R101 was admitted to the facility on [DATE]. Diagnoses includes essential hypertension, major depressive disorder, and epilepsy, unspecified, not intractable without status epilepticus. Review of an Elopement Risk Guide located in R101's paper chart under the Assessments tab and dated 03/20/17 indicated a score of 2 of 5 indicating low risk for elopement. It further indicated, R101 was independently mobile, has no history of elopement/elopement from prior settings, no verbalized plans to leave the facility whether or not authorized, no expressed desire to leave the facility Against Medical Advice (AMA), no disregard for facility policies and procedures related to leaves of absences, and no history of wandering behaviors. Review of an Interdisciplinary Team Meeting Form, located in R101's paper chart under the Notes tab and dated 02/24/21 indicated, Likes to ambulate around the building, socializing . keeps busy on his own throughout the day by talking to peers, visiting with rehab, ambulating in the facility. Review of a Meeting Note located in R101's paper chart dated 07/28/21 indicated, We discussed the IC [Infection Control] aspect of going out on pass in the community and return to the NH [Nursing Home]. He was reminded of . signing the OOP [out on pass] book when he leaves and comes back, wearing a mask while in the community, stay at least 6 feet apart from others because don't know who is vaccinated or not, no close contacts such as hugging, shaking hands, not accepting any food items from people from the street. Upon return must do proper handwashing, days/times prefers to leave the building and return, and local health dept. [Department] suggest do a rapid test every 2-5 days although he is vaccinated. He acknowledged understanding. Further review of the note revealed no documentation that a care plan would be developed with measurable goals, interventions regarding the possibility of R101 to go for walks into the community. Review of R101's Annual MDS found in the EMR under the MDS tab with an ARD of 02/13/22 indicated, it is Very Important for R101 go outside to get fresh air when the weather is good. Review of R101's Quarterly MDS found in the EMR under the MDS tab with an ARD date of 08/09/22, indicated a BIMS score of 15/15 indicating the resident was cognitively intact. The MDS further indicated no behaviors or wandering or elopement. The MDS indicated, no history of falls within last six months, adequate vision, and No behaviors of wandering. The MDS indicated R101 was independent for bed mobility, transfers, walking in room, walking in corridor, locomotion on and off the unit, dressing, toilet use and personal hygiene. Review of a Care Plan initiated and revised on 08/31/20, found in R101's EMR under the Care Plan tab indicated, [name of R101] is independent with pursuits & socializes with his peers. Interventions listed were: Enjoys being outside in courtyard and dancing to music when weather is warmer, enjoys walking around the building & socializing with his peers. Further review of the care plan located in the EMR revealed no resident person centered care plan specifically developed regarding R101's choice to go for walks in the community, being able to sign himself in/out, where to go, education, meetings held with the resident, or any specific goals, interventions put into place regarding his desire to go for walks into the community. Review of a General Nurses Note located in R101's EMR under the Prog Notes tab dated 08/20/21, indicated, IDCP (Interdisciplinary Team) met . [name of R101] has independent pursuits which include walking around the building and socializing . Was permitted to go for a walk outside the facility this past quarter. He failed to comply with the policy on OOP [Out on Pass] and currently OOP is on hold for [name of R101] to go out himself . The following is addressed in the CP (care plan) . Further review of the note revealed no specific resident centered care plan was developed or implemented specifically with R101 wanting to go outside, specific measurable goals, or any interventions put into place to address wanting to go outside for walks. Review of Social Services Progress Notes located in R101's EMR under the Prog Note tab indicated dates in 2022 in which Interdisciplinary Team (IDT) Meetings were held on 08/19/22, 08/09/22, 07/29/22, 05/20/22, 05/16/22, and 02/14/22 to discuss R101's care. However, there was no discussion or documentation of a person-centered care plan that was developed or implemented to discuss measurable goals and specific interventions put into place to address R101's wishes to go for walks by himself into the community. Review of a Plan of Care Note located in R101's EMR under the Prog Note tab dated 05/20/22, 08/09/22 and 08/19/22, indicated, Meeting took place in resident room with nurse and SWer (social worker) present . awake alert . remains verbally responsive and cam make his needs known to staff . He continues to enjoy spending time in the courtyard . Further review of the Progress Notes revealed no discussion or documentation that took place regarding R101's wishes to go for walks into the community, and no documentation of a person-centered care plan being developed with measurable goals and interventions regarding R101's wishes to go out for walks into the community. During an interview on 08/30/22 at 1:23 PM, the Administrator stated, When I got here as the Administrator in June 2022, I was told just from hearsay that there was a history of him [R101] going out and panhandling in the nearby stores . It is a liability due to a history of panhandling back in the day that was a concern. He would say that he always went on walks, but because of his safety, I can't allow him to go on walks by himself. When the Administrator was asked if there was a plan put into place, or a person-centered care plan that shows discussions took place about putting specific measurable goals into place with interventions regarding R101 wanting to go for walks into the community. The Administrator stated, We came up with a plan. I told him I would start taking him on walks. Sometimes we did, and other days he hasn't wanted to go out for a walk. We came up with a schedule but that kept moving. We were all in agreement that is is not safe for him to go on these long walks. This was just all verbal, there is no written plan in place. During an interview on 08/31/22 at 1:26 PM, the Social Services Director (SSD) stated, We have had care plan meetings every quarter but mostly we cover his weight, ADLs, advanced directives, and meds [medications]. He [R101] is considered his own responsible party. We have not discussed anything in his care plans regarding him wanting to go for walks into the community. During an interview on 08/31/22 at 1:36 PM, the DON stated, We started having some discussions about him going for walks back into the community, I want to say in early 2022 but then that administrator left, and we got a new one. Now, we will be starting some more discussions, but we were not officially documenting that in our computer charting. When the DON was asked if she could show documentation of a resident specific person centered care plan that has been developed specifically with measurable goals and interventions, meetings that took place, education, and a plan about R101 going on walks into the community, the DON stated, We have a care plan that was initiated on 02/22/21 but there was nothing specific about this issue. I don't see our discussions on it, or when we have spoken to him about this. The DON stated, He [R101] approached me again this morning about where we were at with him wanting to go for walks into the community. I said to him that I'm working on it. Over the past couple of months, he has proven himself somewhat, but we don't have anything in writing like a care plan of our discussions. 5. Review of the undated Admission Record in the EMR under the Profile tab, revealed Resident (R103) was admitted to the facility on [DATE] with diagnoses including sepsis, hypoglycemia (low blood sugar), acute kidney failure, heart failure, acute respiratory failure, leukemia, protein calorie malnutrition, and type two diabetes mellitus [DM]. Review of the Significant Change MDS with an ARD of 08/12/22 revealed the resident was unimpaired in cognition with a BIMS score of 15 (score of 13 - 15 indicates cognition is intact). During an interview on 08/29/22 at 10:58 AM, R103 and his family member (F)103 were interviewed together. F103 stated R103's blood sugars (BS) had been, terrible recently, with levels between 400 - 500. Review of the Nurses' Notes revealed R103 had low blood sugar (hypoglycemia) on 07/13/22 as follows resulting in hospitalization : Review of a Nurse's Note dated 07/13/22 at 6:51 AM, in the EMR under the Progress Notes tab revealed, BS: 38 mg [milligrams]/dL [deciliter] [65 - 109 normal range per lab] . 2 injections of glucogen [hormone that increase blood sugar level and prevents it from dropping too low] given. Supervisor made aware. Long-acting insulin placed on hold. MD [medical doctor] called awaiting call back for possible d/c [discharge]. BS at 6:45 AM 53 mg/dl. Will keep monitoring. Review of a Nurse's Note dated 07/13/22 at 7:07 AM in the EMR under the Progress Notes tab revealed, Patient remains unresponsive. Patient in high fowlers [seated upright]. Patient given addition glucogen injection. increased to 91 mg/dl and then dropped back to 59 mg/dl. supervisor made aware. Review of a Nurse's Note dated 07/13/22 at 7:15 AM in the EMR under the Progress Notes tab revealed, Patient remains unresponsive. 4th glycogen IM [intramuscular] given. BS: 77mg/dL. MD called awaiting call back. supervisor aware. Review of a Nurse's Note dated 07/13/22 at 07:35 AM in the EMR under the Progress Notes tab revealed, Transfer to ER [emergency room ] due to hypoglycemia. BS: 86 mg/dL. In and out of consciousness. Review of the Insulin Report dated August 2022 in the EMR and under the Orders tab, revealed R103's recent BS levels had been elevated (hyperglycemia) with levels exceeding 500 mg/dL, noted on the following dates: 08/18/22 BS 526; 08/20/22 BS 530; and 08/26/22 BS 512. Review of the Order Summary Report dated August 2022 in the EMR and under the Orders tab, revealed R103's current insulin orders were as follows: -Novolog, inject as per sliding scale: If 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 400 = 6 units; 401 - 450 = 8 units; 451 - 500 = 10 units; 501 - 550 = 12 units, Call physician if BS is less than 60 or more than 550, administer subcutaneously two times a day for DM, accucheck at 8:00 AM & 4:00 PM with sliding scale, initiated on 08/27/2022. -Insulin Glargine-yfgn Subcutaneous Solution 100 unit/ML, inject 26 unit subcutaneously at bedtime for DM initiated on 08/26/22. During an interview on 08/30/22 at 01:23 PM, LPN5 and LPN1 stated there had also been multiple insulin adjustments made to R103's regimen due to recent incidents of hyperglycemia. R103 received nutrition via a feeding tube and the formula had been changed due to high blood sugars. R103 was served a pureed diet; however, he did not eat it. R103's Care Plan dated 07/11/22 in the EMR under the Care Plan tab was reviewed. There was no care plan specific for the problem of diabetes mellitus, to address hypoglycemia or hyperglycemia. Review of the Care Plan dated 07/30/22 in the EMR under the Care Plan tab revealed the only reference to DM was as follows: [R103] is at risk for skin impairment r/t impaired mobility, incontinence, DX: DM, CA [cancer], at risk for malnutrition . The goal was [R103] will have no further skin breakdown x 90 days. Interventions included, B/L [bilateral] heel floats for protection offload heels when in bed; DM management as ordered, podiatry consults as needed; Monitor peg [percutaneous endoscopic gastrostomy] site for s/s [signs and symptoms] of infection. Treatment as ordered; Reposition every 2 hours as needed; Toileting hygiene/incontinence care in a timely manner; Weekly skin assessments. Pressure reducing mattress to bed. Dietitian to follow with recommendations. Roho cushion for chair. During an interview on 09/01/22 at 4:12 PM, the DON stated the MDS nurse was currently out of the facility and not available for interview. The DON verified R103 had a diagnosis of diabetes mellitus and stated R103's blood sugars had been significantly elevated recently. The DON also verified previous incidents of hypoglycemia due to the resident failing to eat. The DON stated the physician changed the resident's insulin dose several times and his tube feeding formula in response to the elevated BS. The DON stated she was not aware that the resident's diagnosis of diabetes mellitus and incidents of hypoglycemia and hyperglycemia had not been care planned and she verified diabetes mellitus should be care planned. The DON stated she would review the care plan and if she found any pertinent information, she would provide it. No additional information was provided to illustrate DM was care planned for R103. Review of the 02/01/22 facility policy titled Comprehensive Resident Centered Care Plans showed: Intent . Every resident will have an Interdisciplinary Care Plan. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. There will be ongoing documentation of the nursing process related to resident needs from admission to discharge. The interdisciplinary plan of care will be developed through collaborative efforts of the Interdisciplinary Team and other health care professionals. It will be consistent with the medical plan of care and those disciplines that have direct involvement with the resident's care It is our purpose to ensure that each resident is provided with individualized, goal directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care. Review of the Resident Assessment Instrument [RAI] Manual, dated October 2019, page 4-8, showed: .4.7 The RAI and Care Planning As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. NJAC 8:39-11.2(i)

Based on observation, interviews, record review, and review of the facility policies, the facility failed to report to administration when one of two residents (Resident (R) 68) in a total sample of 25 experienced a resident-to-resident altercation. This failure placed the residents at risk for further altercations and a diminished quality of life. Findings included: 1. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R68 was admitted to the facility on [DATE] with diagnoses that included fragile X chromosome abnormality (an inherited condition characterized by an X chromosome abnormality which tends to have limited intellectual disabilities.) Review of the 05/13/20 Behavior Care Plan located in the Care Plan tab of the EMR revealed, .Behaviors: laughing/talking to self loudly, yelling out, vocal outbursts, kicking/hitting staff, scratching self, wandering into others' rooms and touching others belongings, looking for snacks, attempting to use bathroom several times, constantly wanting fluids, patient tries to hit other patients if she thinks the patient is looking at her, throwing coffee cup, going through dirty dishes on the tray, pulling her own hair, attempting to put toilet papers in her mouth (after soaking it in toilet.) Aggression towards others [sic] hit/kicks . Review of the quarterly Minimum Data Set (MDS) assessment with and Assessment Reference Date (ARD) of 07/15/22 revealed, R68 had a Brief Interview of Mental Status (BIMS) of 03 out of 15 which indicated she was severely impaired in cognition for daily decision-making and had no behaviors. Review of the Admission Record located in the Profile tab of the EMR revealed, R22 was admitted to the facility on [DATE] with diagnoses which included Rheumatoid arthritis and heart disease. Review of the quarterly MDS assessment with ARD of 06/13/22 revealed, R22 had a BIMS of 13 out of 15 which indicated she was cognitively intact for daily decision-making. During a random observation on 08/29/22 at 10:37 AM, R68 was observed walking into R22's room (which was the room next door.) R22 was observed seated in her wheelchair at the foot of her bed. R68 began to yell at R22 to give her food and R68 became upset verbally when R22 told her no, and to leave her room. R68 started to leave R22's room and saw the surveyor in the hall outside the room. R68 showed the surveyor that she had obtained a package of cookies and then put them into her pocket. R68 was very unsteady while holding onto the handrail and stopped just outside her room door. This surveyor noted that no staff, licensed or certified, was in the hallways. On 08/29/22 at 10:40 AM, Registered Nurse (RN) 2 was observed at the far end of the hall at the medication cart. RN2 was told about the altercation and was asked about R68's behaviors. RN2 stated that R68 was not combative but had wandered into other residents' rooms in the past but had not done this for long-time. RN2 stated that R68 was not to be up walking independently and that most of her behaviors centered around asking for food and drinks. During an interview on 08/30/22 at 3:29 PM, Licensed Practical Nurse (LPN) 2 was asked if she had been made aware of the verbal altercation between R68 and R22 on 08/29/22. LPN2 stated, No, I did not know. LPN2 was asked what she would do if she witnessed or had become aware of a resident-to-resident altercation. LPN2 stated she would separate the residents to make sure they were safe and to monitor them for any affects. LPN2 was asked who would be notified of the altercation to ensure there was no potential abuse. LPN2 stated, The DON [Director of Nursing]. During an interview on 08/30/22 at 1:33 PM, LPN3 was asked if she had been made aware of the altercation between R68 and R22. LPN3 stated, No, I had not heard that she had gone into R22's room and yelled at her. LPN3 further stated that at one time, R68's behaviors were very bad, and we had to one-to-one her, but since then she has calmed down. During an interview on 08/31/22 at 10:23 AM, the Social Services Director (SSD) was asked if she had been made aware of the altercation between R68 and R22. SSD stated, No, I wasn't aware of it, and no one informed me. During an interview on 08/31/22 at 10:27 AM, the Director of Nursing (DON) was asked if she was made aware of the altercation between R68 and R22 on 08/29/22. She stated no. The DON was told about the altercation that was witnessed and was reported to RN2. The DON stated, Then it should have been reported to me. The DON further stated that an incident report should have been done to rule out potential abuse, statements should have been collected and interview with R22. The DON stated that RN2 was the night supervisor however, she should have told me, that is our policy. During an interview on 08/31/22 at 3:51 PM, R22 was asked about the altercation with R68 on 8/29/22. R22 stated, Yes, she comes in my room all the time. She will take food off my table, drink my drinks, it's very upsetting to me. She will get very loud sometimes, and I tell her to leave. What bothers me is that when I'm asleep and I wake up, there she is, and it scares me. She has never hit me, but she talks loud to me. Review of the facility policy titled, Resident to Resident Altercations, dated July 2021 revealed, .All altercations, including those that may represent resident-to-resident abuse, shall be investigated, and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator . Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents must be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator . If two residents are involved in an altercation, staff will . Complete an incident/accident report and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record .

Based on interview and record review, the facility failed to notify the state mental health authority after a significant change in condition for one (Resident (R) 68) of three sample residents who were reviewed for Preadmission Screening and Resident Review (PASARR- a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness). This has the potential for failure for the facility to identify the resident's needs and provided services appropriate for the residents mental health. Finding included: 1. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R68 was admitted to the facility on [DATE] with a diagnosis of fragile X chromosome abnormality (an inherited condition characterized by an X chromosome abnormality which tends to have limited intellectual disabilities.) Review of the 05/05/20 Level I PASARR located in the Miscellaneous tab of the EMR revealed, R68 was marked positive for intellectual disabilities/developmental disabilities (ID/DD) and a Level II PASARR (a more in-depth evaluation) would need to be completed. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/09/20 revealed, R68 had a Brief Interview of Mental Status (BIMS) of 03 out of 15 which indicated R68 was severely impaired in cognition; and had physical, verbal, and other type behavior for one to three days during the seven-day observation period. In addition, the assessment showed R68 required extensive assistance of one staff for activities of daily living (ADLs), was totally incontinent of bowel and bladder, and was administered an antianxiety medication daily. Review of the 08/11/20 Level II PASARR located in the Miscellaneous tab of the EMR revealed she was not referred for services related to her Severe physical illness-CVA [stroke]. Review of the 05/13/20 Care Plan located in the Care Plan tab of the EMR revealed an update on 08/13/20 which showed, R68 is noted with cognitive impairment secondary to dx [diagnosis]: Fragile X Syndrome, DD, history of CVA with aphasia [a language disorder that affects a person's ability to communicate]. She is able to make needs known using gestures, facial expressions or one-word answers. She understands simple, direct communication from staff. [R68] is exempt from the PASSR [sic] process due to severely impaired cognition. Review of the current quarterly MDS assessment with an ARD of 07/15/22 revealed, R68 had a BIMS of 03 out of 15, required limited assistance with ADL's, had no behaviors, was rarely incontinent of bladder, continent of bowel and was on an antipsychotic medication and antianxiety medication daily during the observation period. During an interview on 08/31/22 at 2:52 PM, the Social Services Director (SSD) was asked if R68 had improved since the previous assessment due to her ambulating on her own, had improved in her ability to perform ADLs, behaviors had improved, and she had started on an antipsychotic medication, would the expectation be that a change in her condition and behavior management warrant a new Level II PASARR. The SSD confirmed and verified that a new Level II PASARR should have been done as she, might have missed out on something that she may have benefited from. Review of the facility policy titled, Coordination - Pre-Admission Screening and Resident Review (PASRR) program, dated 02/01/22 revealed, .A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. NJAC 8:39-5.1(a)

20402 Based on observation, interview, record review, and facility policy review, the facility failed to ensure that the resident and/or the resident's responsible party (RP) for two of two residents (Residents (R) 61 and R103) reviewed for baseline care plans, had baseline care plans developed and implemented to address the resident's immediate needs within 48 hours of admission to the facility. The facility failed to ensure the residents and/or representatives were in attendance of a baseline care plan and provided with a written summary of the baseline care plan that included, at a minimum, the initial goals of the resident; medications, nursing, and dietary instructions; and services and treatments to be administered by the facility and personnel. Findings include: Review of the facility's 02/02/22 policy titled, Baseline Care Plan, indicated, Intent: Every resident will have an Interdisciplinary Care Plan, with the Baseline Care Plan completed within 48 hours of admission. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident . The interdisciplinary plan of care will be developed through collaborative efforts of the Interdisciplinary Team and other health care professionals . The resident and/or family member will be involved in the care planning . The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational, and environmental needs as appropriate. Procedure: The baseline care plan will: 1. Be developed within 48 hours of a resident's admission. 2. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: a. initial goals based on admission orders. B. physician orders. C. dietary orders. D. Therapy services. E. Social services . 4. The facility will provide the resident and their representative with a summary of the baseline care plan prior to completion of the comprehensive care plan, that includes but is not limited to: a. the initial goals of the resident, b. a summary of the resident's medications and dietary instructions, c. any services and treatments to be administered by the facility personnel acting on behalf of the facility . 5. The facility will provide the resident and their representative with a summary of the baseline care plan prior to completion of the comprehensive care plan. 1. During an observation on 08/29/22 at 10:25 AM, R61 was observed laying on his side and sleeping in bed. When attempting to interview the resident, he stated, Sleeping and was not able to further communicate his needs at this time. During an interview on 08/29/22 at 4:13 PM, regarding base line care plans for the care R61 was going to receive, family member (F) 61 (R61's Responsible Party) stated, When he first came to the facility in April, I vaguely recall a discussion that took place, but I never received anything in writing regarding a discussion about the care he was going to receive, or anything called a baseline care plan. No. I never received anything in writing that I recall. During a second interview on 08/31/22 at 12:05 PM, R61 was observed finishing his lunch tray. At this time, the resident was not wanting to be interviewed. Review of a Face Sheet located in R61's electronic medical record (EMR) under the Med (medical) Diag (diagnosis) tab revealed R61 was admitted to the facility on [DATE] with diagnoses to include osteoarthritis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, and type 1 diabetes mellitus. Review of R61's EMR under the Assessment tab indicated no documentation for a baseline care plan. Further review of the medical record revealed no documentation that a baseline care plan was completed after admission to the facility on [DATE], or that R61 and F61 received any written documentation of a baseline care plan. Review of a Social Service Admission/Readmission Note located in R61's EMR under the Progress Notes tab dated 04/06/22 (5 days after admission) by the social worker, indicated R61 was admitted to the facility on [DATE] .requires assistance with all ADLs [Activities of Daily Living] . was noted to be declining functionally and medically and was admitted to rehab to regain strength and endurance. Further review of the Social Service notes revealed no documentation that a written summary of a baseline care plan was completed, or discussion with R61 or F61 took place upon admission or written documentation was given to F61. Review of Nursing Notes located in R61's EMR under the Progress Notes tab indicated R61 went out to the hospital and returned to the facility on [DATE]. Review of an Admission Baseline Care Plan, located in R61's EMR under the Assessment tab dated 05/20/22 indicated an admission baseline care plan was initiated on 05/20/22, but no evidence of any written summary of initial goals, treatments, or various disciplines involved was given to R61 or F61 when R61 was readmitted to the facility on [DATE]. The portion of the baseline care plan labeled, Signature of Resident and Representative was blank. During an interview on 09/01/22 at 8:42 AM, regarding baseline care plans, the Social Services Director (SSD) stated, The process for the baseline care plans is I do that within 48 hours of admission, or the next business day. I go up and interview the patient and set up a family meeting with the families. Upon admission, I will set up a meeting with the family or resident and I do my section for social services. Most prefer to do them over the phone, and I do document that I attempted to call the family. When the SSD was asked if she had any documentation to provide that a written summary of the baseline care plan was provided to R61 or F61 and any information discussed from the first admission on 04/01/22, or the re-admission on 05/20/22, to include at a minimum, the initial goals of the resident, medications, nursing, dietary instructions, and any services to be administered by the facility, the SSD stated, No, but going forward, I will ensure that I'm doing that. 2. Review of the undated Admission Record in the EMR under the Profile tab, revealed R103 was admitted to the facility on [DATE] with diagnoses including sepsis, hypoglycemia (low blood sugar), acute kidney failure, heart failure, acute respiratory failure, leukemia, protein calorie malnutrition, and type two diabetes mellitus. Review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/22 revealed the resident was unimpaired in cognition with a Brief Interview for Mental Status score (BIMS) of 15 (score of 13 - 15 indicates cognition is intact). Review of the Baseline Care Plan dated 07/08/22 and provided by the facility revealed the care plan was completed by a Registered Nurse (RN) on 07/08/22 following R103's admission to the facility. R103 required one-person physical assistance with most activities of daily living (ADLs). The resident was cognitively intact, alert, frequently incontinent of bladder and incontinent of bowel, received insulin, and had current skin integrity issues. The section for signature of the resident and representative was blank (not filled out). There was no evidence the summary of the baseline care plan including the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services, and treatments to be administered was provided to the resident or family. Review of the Baseline Care Plan dated 08/01/22 and provided by the facility revealed the care plan was completed by the SSD and a Registered Nurse (RN) on 08/01/21 following R103's readmission to the facility on [DATE] after a period of hospitalization . R103 required two-person physical assistance with most ADLs. R103 was alert, had an indwelling catheter, was incontinent of bowel, was a diabetic, had pain, and had current skin integrity issues. The resident was prescribed both a pureed diet and received nutrition via a feeding tube. The resident received physical, occupational and speech therapy. The section for signature of the resident and representative was blank (not filled out). There was no evidence the summary of the baseline care plan was provided to the resident or family. During an interview on 09/01/22 at 10:34 AM, R103 and his family member (F) 103 were interviewed together. F103 stated she had not been to a care plan meeting and had not been provided with a baseline care plan summary initially or following R103's readmission from the hospital on 07/30/22. F103 stated she came to visit R103 daily from around 10:00 AM - 6:00 PM. R103 also denied being given a care plan summary or attending a baseline care plan meeting. During an interview on 09/01/22 at 1:00 PM, the SSD stated she, the nurse, and representatives from other disciplines met usually the day after a resident's admission to discuss the baseline care plan. The SSD stated family members and the residents could attend. The SSD stated if families could not attend, the facility could call them and conduct the meeting over the phone. The SSD stated the facility typically set up a family meeting and reviewed the baseline care plan at the meeting. The SSD stated she documented if a family meeting occurred; however, had not provided a written baseline care plan summary to the resident or family. The SSD stated she would check her records to determine whether R103 or F103 had attended a baseline care plan meeting in person or via the phone. During a follow up interview on 09/01/22 at 1:49 PM, the SSD stated she did not have documentation of giving the base line care plan summary to R103 or F103 within 48 hours of admission or upon readmission. The SSD further stated she had no record of having a baseline care plan meeting with R103 or F103. Review of the facility's 02/02/22 policy titled, Baseline Care Plan, indicated, Intent: Every resident will have an Interdisciplinary Care Plan, with the Baseline Care Plan completed within 48 hours of admission. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident . The interdisciplinary plan of care will be developed through collaborative efforts of the Interdisciplinary Team and other health care professionals . The resident and/or family member will be involved in the care planning . The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational, and environmental needs as appropriate. Procedure: The baseline care plan will: 1. Be developed within 48 hours of a resident's admission. 2. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: a. initial goals based on admission orders. B. physician orders. C. dietary orders. D. Therapy services. E. Social services . 4. The facility will provide the resident and their representative with a summary of the baseline care plan prior to completion of the comprehensive care plan, that includes but is not limited to: a. the initial goals of the resident, b. a summary of the resident's medications and dietary instructions, c. any services and treatments to be administered by the facility personnel acting on behalf of the facility . 5. The facility will provide the resident and their representative with a summary of the baseline care plan prior to completion of the comprehensive care plan. NJAC 8:39-11.2(d)

32513 Based on interview, record review, and review of facility policy, the facility failed to ensure advance directives and Practitioner Orders for Life-Sustaining Treatment (POLST) information was completed and obtained for three of 25 sampled residents (Resident (R) 68, R62, and R105). The failure created the potential for residents to not have their wishes known should they suffer a health emergency. Findings include: 1. Review of R78's Census tab of R78's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Review of R78's diagnoses, located under the Diagnosis tab of her EMR, revealed diagnoses which included chronic atrial fibrillation and atherosclerotic heart disease. Review of R78's Physician's Orders, located in R78's EMR under the Orders tab, revealed the resident had a code status of ''DNR'' (do not resuscitate) resuscitation status. Review of R78's Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/11/22 revealed the facility assessed R78 to have a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated R78 was cognitively impaired. Review of the medical record for R78 under the ''Advance Directives'' tab revealed document titled ''New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST)''. The POLST document was signed by a Physician but undated. Further review of R78's medical record revealed an undated 'Living Will'. During an interview on 08/31/22 at 10:23 AM, the Social Services Director (SSD) confirmed the above findings and stated that an undated POLST was not a completed POLST. 2. Review of the Admission Record located in the Profile tab of the EMR revealed, R62 was admitted to the facility on [DATE] with diagnoses that included dementia and Rhabdomyolysis (A breakdown of muscle tissue that releases a damaging protein into the blood.) Review of the quarterly MDS assessment with an ARD of 07/10/22 revealed R62 had a BIMS of 99 which indicated he was impaired in cognition for daily decision-making and unable to complete the assessment. Review of the undated New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) revealed that R62 had signed the POLST indicating that he requested. Limited treatment. Transferred to the hospital . No artificial nutrition . Do Not Resuscitate . Do Not Intubate [DNI]. In addition, a physician signed the POLST however, the form was not dated and timed, as required, on the POLST form. During an interview on 08/31/22 at 8:52 AM, Licensed Practical Nurse (LPN) 3 was asked to review R62's POLST form, located in the EMR. LPN3 confirmed that there was no date/time, either for the resident or the physician, indicated on the form and was incomplete. During an interview on 08/31/22 at 9:30 AM, the SSD was asked if R62 was cognitively intact to make end-of-life decisions. The SSD stated she had just started working at the facility in January 2022 and was not aware of his cognitive status before she started. The SSD was asked to review R62's POLST form. The SSD confirmed and verified that the POLST form was incomplete as it was not dated, as required on the form. 3. Review of R105's Census tab of R105's EMR revealed he was admitted to the facility on [DATE]. Review of R105's diagnoses, located under the Diagnosis tab of her EMR, revealed diagnoses which included Huntington's disease, gastrostomy status, dysphagia, oropharyngeal phase, and mild protein-calorie malnutrition. Review of R105's Physician's Orders, located in R105's EMR under the Orders tab, revealed the resident had a code status of ''full code'' resuscitation status. Review of R105's admission MDS with an ARD of 08/06/22 revealed the facility assessed R105 to have a BIMS score of 99 which indicated R105 was cognitively impaired and unable to complete the assessment. Review of the medical record for R105 revealed a blank POLST form under the 'Advance Directives' tab. Review of a Social Services progress notes dated 08/05/22 at 11:22 AM in the Progress Notes tab in the EMR revealed ''Advance Directives: [Social Worker] discussed various possibilities/options with Advanced Directives: i.e, DNR, DNI and tube feedings with resident's wife with resident present. Facility protocol re: same discussed. Resident wife verbalized and demonstrated understanding of all discussed. Wife verbalized she has advanced directives at home and will bring facility a copy.'' During an interview on 08/31/22 at 10:23 AM, the SSD stated that Advance Directives information had been provided to R105's spouse on admission and that DSS had made several attempts to discuss Advance Directives with R105's spouse, but the spouse was unwilling to discuss. SSD stated she had no documentation of follow-up discussions with R105's spouse. During a follow-up interview on 08/31/22 at 3:14 PM, SSD stated she spoke with R105's son who stated that the POLST form the family had, was never completed, and requested a fresh form. Review of facility's Policy titled ''Resident Right - Advanced Directive Tracking Program, dated 02/01/22 revealed as follows: ''It is the policy of the facility to honor the advance directives of all residents and to make information available to the resident on how to prepare such directives, should the resident not have them in place or to change existing directives. PROCEDURE: 1. During the admission process the Social Services Director or designee will discuss with each resident and/or the person accompanying the resident the following: a. Whether they have an advance directive such as a health care surrogate designation, living will or durable power of attorney? b. Whether they have a POLST? c. If they have those forms with them? If so, secure copies. If not, inquire as to where the documents can be found. 2. The resident and or the person accompanying them will be given a copy of the advance directives information, including the forms used by the facility, whether they have completed advance directives or not. The resident or the person accompanying them should sign that they have received this information. 4. Social Services or the appropriate designee will carefully review any and all advanced directive related documents to ensure that the information is complete and that the requirements of the law are met. If there is a question it is the responsibility of the reviewer to seek clarification.'' NJAC 8:39-4.1(a)2 NJAC 8:39-9.6(a)

Based on observations, record review, interviews, and review of facility policy, the facility failed to ensure one of one resident's (Resident (R) 101) right to make choices about his life that were important to him, were encouraged. Specifically, the facility failed to ensure R101 could go out for walks into the community, interact with members of the community, and encouraged to promote the self determination of needs for resident. The facility also failed to ensure R101 was being included and updated in any discussions about his choice to go for walks in the community. By not promoting resident choices this resident was left feeling as though his needs were not being met to address his right to go into the community for walks. Findings include: 1. During observation and interview on 08/28/22 at 11:22 AM, R101 was observed walking independently from his room to look out a window on the first floor. R101 was well groomed, wearing shorts, t-shirt, and tennis shoes. During interview R101 stated, I want to go walking. I love going outside and getting fresh air. I used to go outside all the time and walk the neighborhood, talk to people, go down to the police station, the stop shop car dealer place, and just walk the neighborhood. R101 stated, I'm able to walk independently. I feel alive when I'm able to go for walks. Now, I feel depressed because the new administrator says I can't go outside. I get excited when I used to go for walks to get fresh air and just say hi to everyone in the neighborhood. I used to work for a printing company, my son is a police officer, and when able, he will come and get me and sign me out and we spend the day together. At this time, R101 stated, There has been a new administrator that says I can't go for my walks anymore. When asked why, R101 stated, They were saying one time I was trying to bring alcohol in the building for someone, but I was not. This was about a year ago. Now, I'm not able to go outside to walk. I used to sign myself in/out when I came and when I left. They tell me now if I want to go outside, I have to have someone with me, but I used to take my walks everywhere by myself. We've had meetings about this, but I feel they don't want to help me. R101 stated, I even worked with therapy, and they had even asked me why I wasn't going on my walks outside anymore. I just love going outside and talking to people and getting fresh air. Since the COVID pandemic, I make sure I have my mask on, I get my tests and they are negative. During observation on 08/29/22 at 9:00 AM, R101 was observed to be well dressed in shorts, shirt, socks, and tennis shoes. R101 was observed walking from his room (located across the hall from the facility elevator) to the dining room, saying good morning to the staff and other residents, getting a cup of coffee, then returning to his room. During this time, R101 was observed not attempting to elope, wander or take the elevator downstairs to the ground floor, or make any attempts to leave the building. During observation on 08/31/22 at 8:36 AM, R101 was observed to be lying in bed and talking with housekeeping staff in his room. During an observation and interview on 08/31/22 at 10:57 AM, R101 was observed coming out his room, well dressed in shorts, slippers, and t-shirt. R101 stated, I washed my clothes today. Have a good morning. Review of an undated Profile located in R101's electronic medical record (EMR) under the Profile tab revealed R101 was his own responsible party. Review of an undated Admitting Face Sheet located in R101's paper chart also indicated R101 was his own responsible party. Review of R101's medical diagnoses located in R101's EMR under the Med (medical) Diag (diagnosis) tab indicated R101 was admitted to the facility 03/20/17. Diagnoses included essential hypertension; major depressive disorder; and epilepsy, unspecified, not intractable without status epilepticus. Review of an Elopement Risk Guide located in R101's paper chart under the Assessment tab and dated 03/20/17 indicated a score of 2 of 5 indicating low risk for elopement. It further indicated, R101 was independently mobile, had no history of elopement/elopement from prior settings, no verbalized plans to leave the facility whether or not authorized, no expressed desire to leave the facility Against medical Advice (AMA), no disregard for facility policies and procedures related to leaves of absences, and no history of wandering behaviors. Review of Social Progress Notes located in R101's paper chart Social Services tab and dated 01/09/18 indicated, Resident is alert/oriented x3, able to make his needs known. Scored 15/15 [15 out of 15] on BIMS [Brief Interview of Mental Status]. Is OOB [out of bed] daily and ambulates. He enjoys walking out and going for walks. Review of Social Progress Notes dated 07/13/18 indicated, He enjoys being outdoors. Review of Social Progress Notes dated 02/18/19 indicated, He ambulates around facility . He enjoys going for walks. Review of R101's annual Minimum Data Set (MDS) found in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/13/22 indicated, it is Very Important for R101 to choose what clothes to wear, very important to do things with groups of people, and very important to go outside to get fresh air when the weather is good. Review of R101's quarterly MDS found in the EMR under the MDS tab with an ARD date of 05/15/22 revealed the resident had a BIMS score of 12/15, which indicated the resident was cognitively intact. The MDS further indicated R101 was independent for transfers, independent for dressing, and was steady at all times for moving from a seated to standing position, steady at all times when walking, turning around and face the opposite direction while walking, and moving on and off the toilet. The MDS further revealed no behaviors of wandering, or elopement. The MDS indicated R101 was not at risk for falls and has had no falls. Review of a Recreation Department Assessment found in the EMR under the Misc (Miscellaneous) tab dated 08/19/21 and 05/16/22 indicated, Current Hobbies and Interest: like to take walks outside and in building and Outdoors . Cognitive: Alert. Attention Span: normal. Vision: intact. Physical: Ambulatory. Mobility: Independent. Behaviors: None. Review of an Interdisciplinary Team Meeting Form, located in R101's paper chart under the Notes tab and dated 02/24/21 indicated, Likes to ambulate around the building, socializing . keeps busy on his own throughout the day by talking to peers, visiting with rehab, ambulating in the facility. Review of a Meeting Note located in R101's paper chart dated 07/28/21 indicated, We discussed the IC [Infection Control] aspect of going out on pass in the community and return to the NH [Nursing Home]). He was reminded of . signing the OOP [out on pass] book when he leaves and comes back, wearing a mask while in the community, stay at least 6 feet apart from others because don't know who is vaccinated or not, no close contacts such as hugging, shaking hands, not accepting any food items from people from the street. Upon return must do proper handwashing, days/times prefers to leave the building and return, and local health dept. [Department] suggest do a rapid test every 2-5 days although he is vaccinated. He acknowledged understanding. Review of R101's quarterly MDS found in the EMR under the MDS tab with an ARD date of 08/09/22, indicated a BIMS score of 15/15 indicating the resident was cognitively intact. The MDS further indicated no behaviors or wandering or elopement. The MDS indicated, No history of falls within last six months. Vision- adequate. No behaviors of wandering. The MDS indicated R101 was independent for bed mobility, transfers, walking in room, walking in corridor, locomotion on and off the unit, dressing, toilet use and personal hygiene. Review of a Fall Risk Evaluation found in the EMR under the Assessment tab, dated 08/09/22 and 02/13/22 indicated R101 was Low Risk for falls. Review of Progress Notes located in R101's EMR under the Prog (progress) Note tab revealed many different dates from 2018-2021 in which R101 has gone out on pass with family, has signed in/out and has returned within 1-2 hours for various activities. Review of Social Services Progress Notes located in R101's EMR under the Prog Note tab indicated dates in 2022 in which Interdisciplinary Team Meetings (IDT) were held to discuss R101's care. However, there was no documentation of R101's wishes to go outside for walks in the community. Notes indicated, BIMS of 15/15, can make needs known, attends group activities, spending time in courtyard, remains independent with ADLS [activities of daily living], no falls, family is passively involved. Review of an additional Wandering/Elopement Risk Assessment located under the Assessment tab dated 08/31/22, indicated his desire to walk in the community as part of his exercise program . Low risk for elopement. Review of a Release of Responsibility for Leave of Absence located in R101's paper chart revealed multiple dates/times in which R101 has signed himself in/out of the facility. During interview on 08/30/22 at 1:23 PM, the Administrator stated, he had only been the administrator since June 2022 and This is just all hearsay, but before I got here, I had heard from the previous administrator and our DON [Director of Nursing] that said there was a history of him [referring to R101] going out into the community and panhandling, knocking on doors, and buying alcohol in the nearby stores. [R101] would be walking down to the nearby turnpike areas to where we have no way to find out where he is. I told [R101] if he is looking into another facility who could accommodate this, we would assist him in trying to accommodate his needs, but because it is a liability and due to his history of panhandling (again hearsay), that was a concern. The Administrator stated, He [R101] would say that he always went on walks with no problems, but because of his safety, I can't allow him to go on walks by himself. For one, he is not stable on his feet, and he gets tired a lot, and with this area we have a concern of him falling. There was also a history of him going to a liquor store, again this is what I was told, so we came up with a plan. I told him I would start taking him on walks. He was in agreement with this. The Administrator stated, Our plan we came up with was that I would take him for a walk. We set up a schedule, then that was always changing. We did speak to his family. We expressed we had some safety concerns with him just going out for long walks. The Administrator stated, We had a meeting with the team, and we were in agreement that it's not safe for him to go on these long walks. He is able to go out to the courtyard anytime. When the Administrator was asked if there was a written agreement or anything in writing set up with the facility and R101, he stated, No. The Administrator stated, He [R101] can sign himself in/out, but again its what he may do when out in the community when by himself that would be a potential harm. He may bring something to the facility, i.e., alcohol, money, panhandling, but now its frowned upon. From what I'm told, this is all based on his previous history. The Administrator stated, No staff have ever come to me with concerns like he has been trying to get out of the building or targeting any certain staff to let him out to go for a walk. No. Whenever he asks, we can try to schedule to go for a walk with him. He doesn't come to me repeatedly and ask can I go out; can I go out. No, not at all. The Administrator stated, He may have a day where he asks 'can I go out by myself?', and my response is its for your safety you don't. We could work on your gait, balance before you go. Generally, he has pretty good mobility, and has pretty good gait, but due to those safety concerns he can't just go out for walks by himself. During interview, on 08/31/22 at 8:45 AM, Licensed Practical Nurse (LPN) 4 stated, He [referring to R101] will go outside to the back enclosed patio, he is able to do that on his own. He can get in the elevator by himself and go downstairs to the first floor without any problems and out into the courtyard. He likes to go to activities as well on the second floor to keep busy. LPN4 stated, I've never known him [R101] to just go for walks into the community and I've never seen him wanting or trying to leave the facility out into the community. He . is very independent for his ADLs. During interview on 08/31/22 at 9:09 AM, LPN2 stated, I used to do recreational activities and from what I remember, he [R101] liked playing dominoes, he likes to dance, likes karaoke, and singing. LPN2 stated, He used to go for walks in the community before COVID by himself, but I think they stopped it since COVID. I'm not sure if he is doing it now or not. I do remember he would sign himself in/out whenever he would go on his walks. Now, he walks in the outside courtyard. I haven't seen him wanting to leave the building or trying to go into the community now. He is pretty involved in activities. During interview on 08/31/22 at 9:27 AM, Registered Nurse (RN) 1 stated, He [R101] is very independent with is ADLs. I usually see him walking out in the courtyard, but not into the community. I've never known him to just wander off. He likes activities, bingo, movies, entertainment that comes from the community to sing, play music. RN1 stated, He can take his own showers, takes meds [medications] well, and is pretty independent. During interview on 08/31/22 at 9:51 AM, Recreational Assistant (RA) 1 stated, He [R101] comes upstairs on his own for activities, likes to make his own signs, figures, baseball, likes group activities, dominoes, and Spanish music. He also loves to walk around the building. RA1 stated, From what I heard, he is unable to go out into the community. Someone has to be with him. I have not seen him leave for walks into the community by himself . He likes to get exercise and will walk on each floor. He doesn't have to ask to go outside into the courtyard. That is also where the smokers go. He has never tried to leave the building. He stays busy. He can come upstairs whenever he wants to. He sticks with his routine. RA1 then stated, He used to go out into the community years ago and wave to people, then he would come back without any problems, but I'm not sure what happened. During an interview on 08/31/22 at 1:26 PM, the Social Services Director (SSD) stated, she had only heard of R101 wanting to go out for walks in the community as hearsay, and From what I was told, he was waiting for the DON or Administrator to give the approval for him to go on walks on his own. The SSD stated, I do know he was walked with our Administrator at times, and he likes to go on longer walks around the neighborhood. The SSD stated, We have meetings quarterly every three months but, in those meetings, we just talk about things his medications, diet, weight, ADLs, and advanced directives. As far as any specific meetings about going for walks into the community, no. Not that I'm aware of. Since this new administrator started, there hasn't been much talk about him [R101] going out for walks. He [R101] is considered his own responsible person and is pretty independent. During an interview on 08/31/22 at 1:36 PM, the DON stated, Prior to COVID-19, it was ok'd by PT [Physical Therapy] for him [R101] to take walks around the blocks. We gave him that opportunity until things started to change. The DON stated, We were told he started knocking on doors of people who live in the community and asking for money and was also seen by a [convenience] store with a cup begging for money. When the DON was asked when this occurred, she stated, I would say this was in late 2019 and at that time, he was free to go for walks. He would tell us what time he was leaving and would sign himself in/out and he would come back. Then after COVID we started to open things back up again. He wanted to start going out again. So, in late 2021 we had heard that he started going to a liquor store, but we were not sure. The owner of the liquor store had him [R101] on camera as buying some alcohol and paying for it at the register. When the previous administrator asked him about it, at first, he lied to us and said it never happened. Then in this year 2022, he [R101] finally decided to apologize to us and confessed to buying alcohol and was sorry about it. The DON stated, Now this administrator says it's a safety issue. Not only are you going door to door and trying to get money from people but are standing up by the wayside [of a convenience store] begging for money. The DON stated, He [R101] agreed he could walk around the circumference of the facility. He has done well. The DON stated, We are planning on having a discussion to see if we could put a plan into place, but that has not taken place with him yet. We could put a contract in place but that hasn't been put in place yet. We would have to get something set up and discuss with him that he cannot buy anything illegal and is not supposed to go to anybody's houses. His thing is, he just wants to exercise and walk around the block. He likes to wave at the neighbors. We will have to start a new discussion, but I don't have anything in place. He does ask me, 'Are we still discussing when I can go out again.' I tell him, we are working on it. The DON started, This has all been just verbal discussions, we were not documenting anything in his chart that we have a current plan in place . The only thing that we could actually prove that was he was at the alcohol store in 2019. He has been our only patient that has gone out for walks. In early 2022, we started having some talks again with the previous administrator, then he left, but nothing has been in writing. When the DON was asked if there would be any reason R101 could not go out into the community for walks, the DON stated, Well, no. PT gave us the green light that he can walk by himself. Make sure he watches for uneven surfaces. We think it is more of a behavior issue to make sure he is not knocking on doors. I will have to have another discussion with our administrator to see if he will give the green light. The DON stated, His BIMS is 15/15, he is not an elopement risk. He has never been an elopement risk. He is also a low risk for falls. The DON stated, He [R101] approached me again today to ask, 'Are you working on me going out in the community?' I said, we are working on it. We don't have any concerns about him trying to elope or escape. No. He is alert, walks around independently. PT made sure he was safe to walk on sidewalks, cross the street, and make sure he uses the stop light. During an interview on 08/31/22 at 2:16 PM, the Receptionist stated, Everybody coming into the building I make sure they sign in/out into the Kiosk and get screened. Before COVID, she stated, He [R101] has had privileges of going out into the community. He would come and go. He would sign himself in/out and tell me he was going for walks in the community. The receptionist stated, He would sign out on the 'Resident Sign out Form' where we put a time in and time out. I would see him personally sign himself in/out and I would always check with the nurses as well who would verify he was going out. The receptionist stated, After COVID, I've seen him with his son who has signed him out to go grocery shopping then comes right back. During an observation and interview on 09/01/22 at 7:50 AM, R101 was observed coming out of his room and walking independently to the dining room. During interview R101 stated, I asked the Administrator for an update on me being able to go outside for my walks. He used to take me out, just to go around the building, but that is not really walking to me. They don't feel comfortable with me walking out there I guess. R101 then stated, I said I just want to walk outside by myself. I say hi to people. Every time before, I had to sign in/out which I did, but there is nothing set up like a contract. Too many people smoke in the courtyard. I don't smoke. The last time I walked with the Administrator was a couple of months ago. Like only two times that we went out. The previous guy gave me the okay and just to be careful. R101 stated, As soon as I eat my breakfast, I would like to go out for just an hour and go outside. I like to come back about 10:30 AM or so. I like to take my time and say good morning, say hi to people. This stopped with the pandemic and nothing now. The previous guy in charge use to see me go for my walks. When I asked the director lady [referring to the Director of Nursing] yesterday about it, she just said, 'We are working on it. We are waiting for the state to give the okay'. R101 stated, I feel happy, excited, healthier to get some fresh air. I always make sure I have my mask on due to the pandemic. I'm not a troublemaker. I just love saying hello to everyone. When R101 was asked if there were any rules that were discussed with him about going outside by himself for walks, R101 stated, Just to make sure I keep social distance, keep aware of driveways. Wash my hands. R101 stated, Even my family knows how I am. My son comes to get me every three months. He is a police officer. I don't drink and I don't smoke. I just do my walking. Sometimes people will give me a couple of bucks or give me a cup of water in the summertime. At one time I had my own water bottle. R101 stated, The new Administrator says he is just not comfortable with me walking out by myself because he is new here. I respect the rules, I take my cane with me. During interview on 09/01/22 at 7:58 AM, LPN6 stated, Before COVID-19 he [R101] would walk back and forth into the community. After COVID, it was rumors that people had seen him begging for money. One person who worked here who no longer works here had said he was knocking on doors, but I don't know if that was true or not. We just told him because of COVID, to be careful. LPN6 stated, He just stays around here now. He is a very social person. I think they started letting him walk around the building and he does okay with that. For some reason, someone said something then it stopped. LPN6 stated, He is good about wearing his mask when he goes outside. When asked if there was something like a written contract in place for R101 to continue to go outside for walks into the community, LPN6 stated, No, there is nothing like that in place at this time. No. He can walk around the building, but not all the way into the community. No. During interview on 09/01/22 at 12:15 PM, the Director of Rehabilitation stated, Back in 2019 he [R101] used to be on rehab and we started doing training on walking in the community. He was very independent. Then there was a different Administrator that at one time showed him how far he could go. He would come back. Just would make big circles in the community, then would come back. Then, I'm not sure, but something happened so that stopped. We tried sending out a recreation aide in the past. I've seen him walking and up until I left in 2019, he was taking all the appropriate precautions to cross the road. We have not seen him since the COVID pandemic and since 2019. During interview on 09/01/22 at 2:30 PM, the DON stated, We are going to start to put a plan in place for him, but we have not actually sat down and talked to him as of yet. We don't have a plan in place as of yet and have not set up an actual meeting with him and everyone. From 07/28/21 until now I guess we were just trying to see how he would do with the walks he was taking. Review of the facility's undated policy titled, Resident Self Determination and Participation, indicated, Our facility respects the right of each resident to exercise his or her autonomy regarding with the resident considers to be important facets if his or her life. 1. Each resident is allowed to choose activities . that are consistent with his or her interests, values, assessments, and plans of care including: a. daily routine. 3. Residents are encouraged to make choices about aspects of their lives including . interacting with . members of the community; and participating in community activities inside and outside the facility. Review of the facility's 02/01/22 policy titled, Resident Right-Self Determination, indicated, The resident has the right to, and the facility will promote and facilitate resident self-determination through support of resident choice, including but not limited to the following: b. The resident has a right to make choices about aspects of his or her life that are significant to the resident . The resident has a right to interact with members of the community. Review of the facility's 02/01/22 policy titled, Resident Right-Respect, Dignity/Right to have Personal Property, indicated, Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care. Review of an undated Admission Agreement- Appendix: Resident Rights, indicated, As a nursing home resident, you have certain rights . Certain rights are . Leave the Nursing Home: Leaving for visits: If your health allows . you can spend time away from the nursing home visiting family or friends during the day or overnight. NJAC 8:39-4.1(a)25 NJAC 8:39-7.3(a)

Based on observation, interview, and record review, the facility failed to ensure the care plan was updated for one of 29 residents (Resident (R) 96) reviewed. The failure to keep a care plan current could affect the appropriateness of care provided to any of the 127 current residents receiving care in the facility. Findings include: 1. Observation of R96 on 08/29/22 at 12:45 PM showed a tube feeding running at 65 milliliters per hour that was dated as hung on 08/29/22 at 11:00 PM. Review of R96's Admission Record printed from the electronic medical record (EMR) Profile tab showed an admitted [DATE], and a readmitted [DATE], with medical diagnoses that included pneumonia, hypertension, dysphagia, moderate protein calorie malnutrition, dementia with behavioral disturbance, major depressive disorder, generalized anxiety disorder, and gastrostomy. Review of R96's Progress Notes, from the EMR Prog Notes tab showed: 8/26/2022 12:09 [12:09 PM] General Nurses Note Note Text: .Resident is presently NPO [nothing by mouth] receiving jevity [sic] 1.2 at 65cc [cubic centimeters or milliliters]/hr [hour] for 20hrs totaling 1300ml [milliliters]. Dietician notified and will make adjustments to Jevity order. MD [name] and [Resident Representative name] notified. Review of a discharge Minimum Data Set [MDS], assessment reference date (ARD) 07/22/22 showed R96 was not coded for receiving enteral [tube] feeding. The significant change of status MDS ARD 08/02/22 showed R96 was coded for receiving enteral feeding. Review of R96's care plan from the EMR Care Plan tab showed: Focus: [R96 name] has a nutritional problem or potential nutritional problem r/t [related to] therapeutic diet, altered consistency, . asp [aspiration] PNA [pneumonia], malnutrition, PEG [percutaneous endoscopic gastrostomy tube] placed 7/29. Date Initiated: 10/18/2020 Revision on: 08/03/2022 Goal: [R96 name] will maintain adequate nutritional status as evidenced by maintaining weight within 5% of CBW [current body weight], no s/sx [signs/symptoms] of malnutrition, and consuming at least 75% of at least 3 meals daily through review date. Date Initiated: 10/18/2020 Revision on: 07/04/2022 Target Date: 11/03/2022 . -Monitor/document/report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Date Initiated: 10/18/2020 . During an interview on 08/31/22 at 4:54 PM regarding the references to three meals a day and issues with food in the mouth, the Director of Nursing (DON) stated, Yes, his care plan should have been updated by now. Review of the 02/01/22 facility policy titled Comprehensive Resident Centered Care Plans showed: Intent . Every resident will have an Interdisciplinary Care Plan. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. Procedure:. 2. The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under S483.24, S483.25 or S483.40; . Developing the Care Plan: 1. A comprehensive care plan will be: . c. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. . Updating Care Plans: 1. Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals. 2. Meetings of the Director of Nursing, Social Services Coordinator (if appropriate), MDS Coordinator, Registered Dietitian, Activities Director and Therapy Professional are held to review the current status of skilled residents and determine needed interventions to meet resident goals. The Care Plan will be updated and/or revised for the following reasons: a. Significant change in the resident's condition. b. A change in planned interventions. NJAC 8:39-11.2(h)

Based on observations, interview, record review, and policy review, the facility failed to ensure one of seven residents (Resident (R) 66) reviewed for falls received appropriate care and services following an unwitnessed fall in which she sustained a bruise below her eye. Neurological (neuro) checks were not completed to rule out a head injury after the fall. Findings include: 1. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R66 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, history of cerebral infarction (stroke), osteoarthritis, type two diabetes mellitus, and abnormalities of gait and mobility. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/13/22 in the EMR under the MDS tab revealed R66 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 10 (score of 8 - 12 indicates moderate cognitive impairment) out of 15. R66 required limited assistance from one person for transfers and walking in her room and in the corridor. R66 had not experienced any falls in the preceding six-month period. Review of the Care Plan dated 07/14/22 in the EMR under the Care Plan tab revealed the problem of, [R66] is at risk for falls r/t [related to] impaired mobility, narcotic for pain, poor safety awareness. The goal was for R66 to be free of falls with injury. The care plan revealed, The resident has had an actual fall on 07/25/22 with no apparent injuries due to poor balance. Patient said her knee gave out . The resident will resume usual activities without further incident through the review date. Review of a General Nurses Note dated 07/24/22 at 11:30 PM in the EMR under the Progress Notes tab documented in full, Found sitted [sic] on the floor. Denies pain. Able to stand with assistance and walk. Review of the #791 Fall investigation dated 07/25/22 at 5:44 AM and provided by the facility revealed R66 was found sitting on the floor in her room and had experienced an unwitnessed fall. The investigation noted R66 was assessed and was not in pain, her range of motion (ROM) was good, and she was able to stand and walk. The investigation documented vital signs were taken, and R66 was confused and unable to give a description of the incident. The investigation noted a two-by-two bruise to the left corner of her eye, R66 denied pain or discomfort. Per the investigation, R66's family and physician were notified. R66 was noted to have a gait imbalance, impaired memory, and her walker was not next to her. Review of the Neuro Checks form dated 07/25/22 at 5:44 AM and provided by the facility revealed staff completed neuro checks for R66 on 07/24/22 at 11:25 PM which included taking vital signs, determining orientation, level of consciousness, observed pupils, general response, and evaluation of pain. No additional Neuro Checks forms were completed for 72 hours after the fall in accordance with facility policy. During an observation on 08/30/22 at 10:17 AM, R66 was sitting in a chair in her spouse's room visiting him (he was also a resident), with a walker located next to the chair. R66 stated she walked with a walker and visited her husband who lived at the other end of the hallway. R66 stated she was mostly independent with activities of daily living. R66 verified she had fallen shortly after she was admitted to the facility; however, did not have any additional falls after that time. R66 was unable to provide specific information about the fall that occurred in July 2022. During an interview on 09/01/22 at 3:15 PM, Licensed Practical Nurse (LPN)5 and (LPN)1 stated if a resident fell , the Registered Nurse (RN) on duty completed an assessment. LPN1 stated when a resident hit their head or if it was unwitnessed, the nurses completed neuro checks in the computer, if directed to do so by the physician, to rule out a head injury. LPN1 showed the surveyor a document posted at the nursing station with the parameters for neuro checks. The undated Neuro Checks as Follows document indicated neuro checks should be completed every 15 minutes for the first hour, every hour for four hours, every two hours for four hours, and every eight hours for three days. LPN1 reviewed the EMR and stated there was one set of neuro checks completed on 07/25/22 following R66's fall. LPN1 stated she could not tell if the physician ordered neuro checks to be completed or not because this information went away, and she could not retrieve it. LPN1 verified there were no other neuro checks completed. During an interview on 09/01/22 at 3:57 PM, Registered Nurse (RN) 2 stated there had been a recent change in policy to complete neuro checks in the computer versus on paper. RN2 stated the facility protocol called for neuro checks to be completed every 15 minutes for the first hour, every hour for the next four hours, every two hours for the next four hours, then every eight hours for three days. RN2 stated, at times it was difficult to get all the neuro checks completed due to high use of agency nursing staff. During an interview on 09/01/22 at 4:35 PM , the DON stated R66's fall occurred early in the morning on 07/25/22 and not on 07/24/22. The DON stated, if a resident experienced a fall and hit their head, neuro checks had to be completed or the resident had to go to the hospital for a CT scan. The DON verified one neuro check was completed for resident R66 and if the physician wanted more neuro checks, such as if there was a change in mental status, the physician would have ordered additional checks. The DON verified R66 was noted with a bruise below her eye after the fall. The DON further stated R66 did not experience a change in mental status so additional neuro checks were not warranted. The DON stated the facility did not have a specific neuro check policy. The DON verified the facility's Fall Reduction Program policy directed documentation of neuro checks for 72 hours and the policy did not specify a physician's order was necessary to proceed. Review of the Fall Reduction Program policy dated 02/01/22 and provided by the facility revealed, All residents will receive adequate supervision, assistance and assistive devices to aid in the prevention of falls. Investigative guidelines A. Check resident for injuries . ii. Neuro-checks, for head injuries or unwitnessed fall and resident unable to communicate if he hit his/her head . Document in the Nurse's Notes: i. Observed circumstances; resident fell , slid from chair, found on floor, etc . Neuro-checks . Each nurse, each shift will observe resident and document for 72 hours in the resident's medical record. i. Vital Signs ii. Neuro-checks iii. Neurological changes . Nursing staff is to document Q [every] shift for 72 hours. NJAC 8:39-27.1(a)

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer two of five residents (Resident (R) 31 and R103) reviewed for pneumonia vaccinations and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer R31 the opportunity to be vaccinated with Pneumococcal polysaccharide vaccine (PPSV23) and if this vaccination was not available to offer one dose of Prevnar 20 (PCV20). The facility failed to offer R103 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) in accordance with nationally recognized standards. Findings include: 1. Review of R31's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R31 was admitted to the facility on [DATE] and was older than [AGE] years of age at the time of admission. Review of the Immunizations located in the Immunization tab of the EMR revealed R31 had historical documentation that he had received the PCV-13 on 02/20/20 however, when he admitted to the facility, he was not offered the PPSV-23 or PCV-20, as recommended. There was no documentation to show that he had refused the second vaccine. During an interview on 08/31/22 at 9:35 AM, the Infection Control Preventionist (ICP) stated that she had been employed at the facility for the last six months and was not aware that R31 was not offered or refused the PCV-20 or PPSV-23. 2. Review of the Admission Record located in the Profile tab of the EMR revealed, R103 was admitted to the facility on [DATE] and was older than [AGE] years of age at the time of admission. Review of the Immunizations located in the Immunization tab of the EMR revealed R103 had a documented pneumonia however, there was no indication of the type of pneumonia vaccine R103 had or documentation to show if R103 would potentially require an additional dose. During an interview on 08/31/22 at 9:35 AM, the ICP stated that she had reached out to the R103's physician to determine which vaccine he had but had not heard back since he admitted in July. Review of Center of Disease Control (CDC) website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The tables below provide detailed information . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . The CDC guidelines went into effect on 10/21/21 per recommendations from the Advisory Committee on Immunization Practices (ACIP). Review of the facility policy titled, Pneumococcal Vaccine, dated 2021, revealed, .All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal Infections . Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of pneumococcal vaccination status will be conducted with five (5) working days of the resident's admission if not conducted prior to admission. NJAC 8:39-19.4(i)

Based on interview and record review, the facility failed to identify the need for a new Preadmission Screening and Resident Review (PASARR-a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness) when a resident had a new diagnosis of mental illness for one of three residents (Resident (R) 17) reviewed for PASARR. This failure placed R17 at risk for not receiving necessary services for her mental health. Findings included: 1. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R17 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder. Review of the 06/18/18 Level I PASARR located in the Miscellaneous tab of the EMR revealed, R17 had a diagnosis of major depressive disorder and did not require a Level II evaluation (an evaluation to identify specialized services required by the resident for conditions identified in a Level I). Review of the Medical Diagnosis List located in the Medical Diagnosis tab of the EMR revealed on 05/16/21, R17 had a new diagnosis of bipolar disorder (a mental illness characterized by both manic and depressive episodes.) Review of the EMR did not show that a new Level I screening had been obtained to determine if R17 required a Level II evaluation for the new diagnosis of a serious mental illness. Review of the annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/06/22 revealed, R17 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 which indicated she was cognitively intact for daily decision-making, had verbal behaviors for four to six days and other behaviors for one to three days during the seven-day observation period. In addition, the assessment indicated that these behaviors were worse since her previous assessment. During an interview on 08/31/22 at 9:17 AM, Social Services Director (SSD) was asked if a new Level I PASARR was done in May 2021. The SSD stated, No, it appears that one should have been done especially with the diagnosis change. Review of the facility policy titled, Coordination - Pre-Admission Screening and Resident Review (PASRR) program, dated 02/01/22 revealed, .A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. NJAC 8:39-5.1(a) NJAC 8:39-11.2(a)

C #: Covid-19 Infection Control Survey Based on observation, interviews, and record review on 4/28/22 and 5/3/22, it was determined that the facility failed to ensure handwashing was performed according to their policy and acceptable standards of infection control practice according to the Centers for Disease Control and Prevention (CDC). This deficient practice was identified for 4 of 5 Certified Nursing Assistants (CNAs' #1, #2, #3, and #4) observed for Handwashing technique. This deficient practice was evidenced by the following: Reference: According to the Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR) Guideline for Hand Hygiene in Health-Care Settings, dated October 25 2002, showed .Recommendations: 2. Hand-hygiene technique .B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse the hands with water and dry thoroughly with a disposable towel . Reviewed of the facility line listing (LL) provided by the facility on 4/28/22, showed that the Covid-19 outbreak started on 4/15/22 involving CNA #5 and the last tested positive for COVID 19 was on 4/22/22. During the tour of the units (North and South) the surveyor observed handwashing technique which were not according to the facility policy and acceptable standard of practice: On 4/28/22, Unit North 1: At 10:20 am, CNA #1, performed handwashing with soap and water for 9 seconds. At 10:45 am, CNA #2, performed handwashing with soap and water for 9 seconds. On 5/3/22, Unit South 1 At 10:35 am, CNA #3 after she provided incontinence care to Resident #A, the CNA performed handwashing for 4 seconds. At 11:12 am, CNA #4 performed handwashing with soap and water for 2 seconds. During the interview with CNAs #1, #2, #3, and #4 on 4/28/22 and 5/3/22 from 10:22 am to 12:00 pm, they stated they sang the word happy birthday twice but did not sing the whole happy birthday song which would make it 20 seconds. They further stated that ensuring proper handwashing would help prevent spread of infections. During the interview with the Infection Control Preventionist (ICP), Director of Nursing (DON), and Nurse Educator (NE) on 5/3/22 from 12:50 pm to 2:05 pm, they stated that the staff were educated and expected to wash their hands for 20 seconds. They confirmed that the aforementioned hand washing observation was not according to their policy and CDC guidelines. The form HAND WASHING COMPETENCY provided to aforementioned CNAs from 4/22/22 to 5/3/22 showed .Rub all surfaces of hands, fingers, and wrist producing 20 seconds friction (Happy Birthday song 2 x) with hands pointing down . The facility's policy titled Handwashing/Hand Hygiene updated on 1/2022, showed This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel residents and visitors .Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers .: Deficiency continued citing at D level. Based on interviews and review of pertinent facility documentation on 4/28/22 and 5/3/22, it was determined that the facility failed to ensure all staff entering the building were screened for Covid-19 signs and symptoms in accordance with the facility policy OUTBREAK RESPONSE PLAN and Coronavirus Disease (COVID-19) and Centers for Disease Control and Prevention (CDC) guidelines for 3 of 10 Employees (CNAs' #5, #6, and #7) reviewed for Covid-19 Screening. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/22, showed .1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP [Health Care Provider] should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2 . Review of the facility line listing (LL) provided by the facility on 4/28/22, showed that the Covid-19 outbreak was first identified on 4/15/22 involving CNA #5 and the last tested positive for COVID 19 was on 4/22/22. The LL further showed that CNA #5 was fully vaccinated. The Investigation Summary (IS) of an outbreak, dated 4/18/22, showed that on 4/15/22 CNA #5 was not feeling well and was sent home at 2:00 pm. The night of 4/15/22, CNA #5 experienced cough, diarrhea, and fever. On 4/16/22, CNA #5 reported to work, however, she requested to be sent home early. On 4/17/22, CNA #5 went to Acute Care Hospital and was tested positive for Covid-19. Reviewed of the Screening Audit (SA) dated 4/16/22 for Unit 1 North for 7:00-3:00 pm to 11:00 pm-7:00 am shifts showed no documentation that CNAs' #5, #6, and #7 screened themselves for signs and symptoms of Covid-19. During the interview with CNA #5 on 4/28/22 at 2:08 pm, she confirmed what was reported on the IS. The CNA revealed that on 4/16/22, she went to work and forgot to screen herself for Covid-19. The CNA stated that she was fully vaccinated and wore appropriate personal protection equipments (PPE) while she was at work on 4/15/22 and 4/16/22. Interviewed with the Receptionist (R #1) on 5/3/22 at 10:01 am, she explained that employees prior to entry would use the Electronic Monitoring System (EMS) to screen themselves for signs and symptoms of Covid-19 such us but not limited: fever, cough, and diarrhea. R #1 could not explain how CNA #5, #6, and #7 entered the building without being screened for Covid-19 symptoms. Interviewed with the Administration including the Infection Control Preventionist (ICP) on 5/3/22 from 10:30 am to 11:00 am, they stated that employees were to self screen for Covid-19 symptoms and should not enter the building if they experience colds or Covid symptoms (fever, diarrhea .) in the last 14 days. The Administration were made aware that 3 out of 10 aforementioned employees failed to self screen for Covid symptoms on 4/16/22. The surveyor attempted to conduct a telephone interview with CNAs #6 and #7 on 5/3/22 at 11:00 am. However, they were not available. The EMS showed but not limited to the following screening questions: Have you or any household members been diagnosed with COVID-19 or experienced any cold or flu-like symptoms in the last 14 Days (including fever, cough, .diarrhea, headache . The facility policy titled OUTBREAK RESPONSE PLAN, undated, showed IT IS THE POLICY OF THIS FACILITY: To effectively manage and contain an outbreak when identified in the facility .MONITORING OF SYMPTOMS: The facility will monitor its residents and employees for the following symptoms as determined by the CDC: Fever Cough .Diarrhea .SCREENING: Anyone entering our facility will actively screened for fever and symptoms of COVID-19 . Review of the facility policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, dated 1/2022, showed .While in the building, personnel are required to strictly adhere to established infection prevention and control polices [policies], including Hand hygiene .Surveillance and reporting of respiratory infections .Anyone entering the facility (including staff) is screened and triaged for signs and symptoms of and exposure to others with [CONDITION(S)]-CoV-2 infection, including: Fever .or subjective fever, Cough .Diarrhea. Anyone with a fever, signs/symptoms of illness .is not allowed to enter the facility . NJAC 8:39-19.4 (a) (1)(b)

Based on observation, interview and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders [REDACTED].#8, #88, #117) reviewed and was evidenced by the following: 1. On 03/07/19 at 10:20 AM, the surveyor observed Resident #8 laying in bed eating breakfast. The surveyor reviewed Resident #8's medical record. According to the Admitting Face Sheet, Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 03/03/19, the facility assessed Resident #8 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The surveyor reviewed the (MONTH) 2019 and (MONTH) 2019 physician's orders [REDACTED].#8's physician had not signed or dated these monthly orders. On 03/13/19 at 9:45 AM, the surveyor interviewed Resident #8 who stated they do not recall the last time the physician was in to visit but they didn't' see the physician often. 2. On 03/07/19 at 10:41 AM, the surveyor observed Resident #117 in the doorway of the room self-propelling in the wheelchair. The surveyor reviewed Resident #117's medical records. According to the Admitting Face Sheet, Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Comprehensive MDS dated [DATE], the facility assessed Resident #117 as cognitively intact with a BIMS score of 15 out of 15. The surveyor reviewed the (MONTH) 2019 and (MONTH) 2019 POF that revealed Resident #117's physician had not signed or dated these monthly orders. On 03/13/19 at 9:49 AM, the surveyor interviewed Resident #117 who reported not remembering the last time physician was in but knows it has been a long time. On 03/12/19 at 1:03 PM, the surveyor interviewed the South One Licensed Practical Nurse Unit Manager (UM) who stated that the night shift checks to make sure physicians orders are signed if they are not signed right away the night nurse notifies the UM and then she would call the physician to come in and sign the orders. 3. On 03/08/19 at 09:33 AM, the surveyor observed Resident #88 in bed with eyes open. The resident was watching television. The surveyor reviewed Resident #88's medical records. According to the Admitting Face Sheet, Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Annual MDS dated [DATE], the facility assessed Resident #88 as cognitively intact with a BIMS score of 12 out of 15. The surveyor reviewed the (MONTH) 2019 and (MONTH) 2019 POF that revealed Resident #88's physician monthly orders had not been signed or dated. On 03/11/19 at 09:15 AM, the surveyor interviewed the North One LPN UM about the physician not signing and dating the monthly orders. She stated that when the physician comes to the facility it is the responsibility of the nurse was working to make sure the physician had signed and dated the monthly orders and wrote progress notes. If the physician forgets to sign and date the monthly orders and doesn't write progress notes the nurses would notify the DON and Administrator. On 03/11/19 at 09:38 AM, the surveyor interviewed the DON about the lack of signatures. She stated she does an audit every two weeks and was constant communication with the physician. The physician tells her he will come in to sign orders, but when she checks the next day, the orders aren't signed. On 03/12/19 at 01:49 PM, the surveyors discussed the above concerns with the DON and Administrator. The DON stated that there was no policy for physician's signing and dating their monthly POF. She further stated the physician's are expected to come in and sign their monthly POF by the second week of the month. NJAC 8:39-27.1

Based on observation, interview and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least every 60 days. This deficient practice continued over several months for 4 of 31 residents (Resident #8, #88, #89, #117) reviewed and was evidenced by the following: 1. On 03/07/19 at 10:20 AM, the surveyor observed Resident #8 laying in bed eating breakfast. The surveyor reviewed Resident #8's medical records. According to the Admitting Face Sheet, Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 03/03/19, the facility assessed Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The surveyor reviewed physician progress notes [REDACTED].#8's physician had not performed a face to face visit and wrote progress notes since 12/19/18. On 03/13/19 at 9:45 AM, the surveyor interviewed Resident #8 who stated he/she does not recall the last time the physician was in to visit but he/she doesn't see the physician often. 2. On 03/07/19 at 10:41, AM the surveyor observed Resident #117 in the doorway of the room self-propelling in the wheelchair. The surveyor reviewed Resident #117's medical records. According to the Admitting Face Sheet, Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Comprehensive MDS dated [DATE], the facility assessed Resident #117 as cognitively intact with a BIMS score of 15 out of 15. The surveyor reviewed physician progress notes [REDACTED].#117's physician had not performed a face to face visit and had not written progress notes since 12/19/18. On 03/12/19 at 9:49 AM, the surveyor interviewed Resident #117 who reported not remembering the last time physician was in but knows it has been a long time. 3. On 03/08/19 at 09:33 AM, the surveyor observed Resident #88 in bed with eyes open. The resident was watching television. The surveyor reviewed Resident #88's medical records. According to the Admitting Face Sheet, Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Annual MDS dated [DATE], the facility assessed Resident #88 as cognitively intact with a BIMS score of 12 out of 15. The surveyor reviewed PPN that revealed Resident #88's physician had not performed a face to face visit and did not write progress notes since 12/19/18. On 03/11/19 at 09:15 AM, the surveyor interviewed the North One LPN UM about the physician not signing and dating the monthly orders. She stated that when the physician comes to the facility it is the responsibility of the nurse who was working to make sure the physician had signed and dated the monthly orders and wrote progress notes. If the physician forgets to sign and date the monthly orders and doesn't write progress notes, the nurses would then notify the DON and Administrator. On 03/11/19 at 09:30 AM, the surveyor interviewed Resident #88 about how often the physician visits. The resident stated that they couldn't recall how often and wasn't sure if they were seen by the physician in the month of (MONTH) or February. On 03/11/19 at 09:38 AM, the surveyor interviewed the DON about the lack of documentation. She stated she does an audit every two weeks and was in constant communication with the physician. She stated the physician tells her he will come in to do the monthly orders and PPN, but when she checks the next day the physician didn't do it. 4. On 03/08/19 09:57 AM, the surveyor observed Resident # 89 sitting in a wheelchair in the day room. The surveyor reviewed Resident #89's medical records. According to the Admitting Face Sheet, Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Significant Change MDS dated [DATE], the facility assessed Resident #89 as cognitively impaired with a BIMS score of 6 out of 15. The surveyor reviewed the PPN that revealed Resident #89's physician had not performed face to face visits from (MONTH) (YEAR) to (MONTH) 2019 and didn't document on the PPN since 07/23/18. The surveyor was unable to interview Resident #89 concerning the frequency of the attending physician's visits due to the resident's cognitive impairment. On 03/12/19 at 01:25 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN UM) who stated she makes sure when Resident #89's physician visits and signs everything, but the physician doesn't always come in during her shift. The RN UM further stated that when the physician does not complete face to face visits she informs the Administrator. She further stated sometimes when the physician comes back to the facility he doesn't do everything. On 03/12/19 at 01:49 PM, the surveyor discussed these concerns with the DON and Administrator. The DON stated that the physicians are expected to come in for face to face visits with the residents, documenting the visit in the PPN at least every 30 days and as needed. The surveyor reviewed the facility's policy and procedure for Physician Assessments and Follow up that indicated under Procedures, section II titled Visits and Documentation the physician or Advanced Practice Nurse (APN) shall visit each resident every 30 days and following the initial visit, alternate 30 day visits may be delegated by a physician to a New Jersey licensed physician assistant. NJAC 8:39-27.1

Based on observation, interview, and record review, it was determined that the facility failed to implement a physician's order for wound care to a stage III pressure ulcer. The pressure ulcer increased in size from 0.2 centimeters (cm) length x 0.2 cm width x 0.1 cm depth to 0.5 cm length x 0.5 cm width x 0.1 cm in depth. This deficient practice was observed for 1 of 5 residents (Resident #104) reviewed. This deficient practice was evidenced by the following: On 02/12/18 at 11:00 AM, the surveyor observed Resident #104 lying on the bed, positioned on the right side with hand rolls in place. The resident was non-verbal. The surveyor reviewed Resident #104's medical records. Resident #104 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the Visit Report for Integrated Wound Care (VRIWC) dated 11/1/17 that indicated that the resident had a stage III pressure ulcer on the left plantar foot which was identified on 11/1/17. The surveyor reviewed the February 2018 Physician's Order Form (POF) and Treatment Administration Record (TAR) which revealed that there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 2/4/18 and the left plantar foot pressure ulcer was documented as healed. The surveyor reviewed the nurses' notes from the dates of 1/2/18 through 2/15/18, which did not have documentation regarding the status of left foot plantar pressure ulcer. There was no documentation in the nurses' notes that indicated why the treatment to the plantar foot was discontinued. The surveyor reviewed the VRIWC form dated 1/31/18 completed by the Nurse Practitioner (NP) which documented, Left, plantar foot is a chronic stage 3 pressure ulcer with measurements of 0.2 centimeter (cm) length x 0.2 cm width x 0.1 cm depth and has received a status of not healed and Continue current treatment. Further review of the VRIWC form dated 2/7/18 and 2/14/18 documented, Left, plantar foot is a chronic stage 3 pressure ulcer with measurements of 0.5 cm length x 0.5 cm width x 0.1 cm depth and has received a status of not healed and Continue current treatment. On 02/16/18 at 10:25 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the resident who stated that the NP completed the VRIWC forms and the reports were given to the Wound Treatment Nurse (WTN) who reviewed them and then placed them in the resident's chart the next day. The LPN stated that all of the staff should review VRIWC form when it is placed in the resident's chart. At 10:35 AM, the surveyor interviewed the WTN who stated, that according to the TAR, the resident's left plantar foot pressure ulcer was healed on 2/4/18, and she had not provided treatment to the resident's foot since the treatment was discontinued. The WTN stated that she reads the VRIWC and files it in the chart and that she must have missed the VRIWC reports dated 2/7/18 and 2/14/18 which documented that the wound was not healed and that the current treatment should be continued. The WTN further stated that the WTN who discontinued the treatment worked on the weekends. The surveyor was unable to get in contact the WTN who discontinued the left plantar foot pressure ulcer on 2/4/18. At 10:44 AM, the surveyor, the Registered Nurse (RN), who was also the facility's , Infection Control Nurse (ICN), and the WTN observed the resident's wound. The WTN lifted the resident's left foot from underneath the blanket and stated that the wound was healed. The RN, ICN stated that the pressure ulcer was not healed. The surveyor observed that there was no dressing on the resident's left plantar foot. At 11:05 AM, the surveyor interviewed the NP who confirmed that the resident does have a Stage III pressure ulcer on the left plantar foot and assumed that the staff was continuing the treatment. The NP stated that the left foot pressure ulcer had a scab on it which she removed on 2/7/18, and further stated that may be why a staff member assessed the left foot plantar pressure ulcer as healed on 2/4/18. She was not aware that the current treatment was discontinued on 2/4/18. The surveyor asked if the NP reviews the POF and the TARs. The NP stated that she did not review these forms. At 1:15 PM, the surveyor discussed the above concerns with the Administrator and the Director of Nursing (DON). On 02/20/18 at 10:00 AM, the Administrator and the DON stated that the pressure ulcer was documented as healed on 2/4/18 and must have re-opened. The treatment and services should have been provided as the NP recommended. NJAC 8:39 11.2(a)

Complaint #: NJ Based on interviews, review of the medical records (MR) and other facility documentation, it was determined that: A. The Licensed Practical Nurse (LPN) practiced out of her scope of practice by assessing 1 of 3 residents (Resident #2) and determining the death of a resident, as well as, failing to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) efforts according to the Healthcare Provider Basic Life Support Standards. In addition, the LPN failed to inform the Registered Nurse Supervisor (RNS) of Resident #2's code status. The RNS failed to assess the resident herself, and relied solely on the LPN's assessment, and the report of death of the resident. The immediate jeopardy which began on [DATE] was lifted on [DATE] at 5:08 PM, when an acceptable plan of correction was provided by the facility. B. The deficiency will continue at a lower scope and severity of a D for the following: The facility nursing staff failed to correctly document if medications were or were not administered on the Medication Administration Record [REDACTED]. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated Title 45: ,[DATE] 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, .and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45: ,[DATE] The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities ., under the direction of a registered nurse or licensed or otherwise legally authorized physician. Reference: Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation an Emergency Cardiovascular Care. The American Heart Association states: Withholding and Withdrawing Referencing CPR (Termination of Resuscitative Efforts) Related to Out-of Hospital [MEDICAL CONDITION] (OHCA) Criteria for Not Starting CPR in All OHCA Basic life support (BLS) training urges all potential rescuers to immediately begin CPR without seeking consent, because any delay in care dramatically decreases the chances of survival. While the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION], there are a few exceptions where withholding CPR might be appropriate, as follows: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril, obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection or decomposition), a valid, signed and dated advance directive indicating that resuscitation is not desired, or a valid, signed and dated DNAR (do not attempt resuscitation) order. A Review of the facility Full Code Policy dated [DATE] indicated the following: In the interest of preserving the dignity and quality of life of its patients, (Facility) honors full code requests. Procedure: 1) Upon admission the resident will be assessed regarding their code status. 2) In case of a medical emergency for these residents, the charge nurse will page CODE SEVEN. All PCC (Patient Care Coordinators) or charge nurses must respond to the location of emergency, and the emergency cart will be brought in the patients location, CPR must be initiated, then 911 must be called and all appropriate measures taken. 3) All residents without a green printed armband will be considered full code status until deemed otherwise. Review of the facility Emergency Policy dated [DATE] indicated the following: Should an emergency situation occur involving one of the resident/employee, appropriate assistance is to be obtained immediately. Procedure: When an emergency situation occurs with a Resident/Employee, you are to follow these guidelines to obtain assistance: a) Someone must stay with the affected person. b) Go to the nearest phone and page CODE 7 and the area where the help is needed. A. According to the Admitting Face Sheet dated [DATE], Resident #2 was admitted to the facility in [DATE] with the [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), an assessment tool dated [DATE], indicated that Resident #2 was cognitively impaired. The MDS documentation included that the Resident required total staff assistance for Activities of Daily Living (ADL's). A review of the interdisciplinary progress note dated [DATE] indicated, Staff discussed options for the resident at this time in order to be as comfortable as possible with the resident's guardian. Guardian maintained she has to follow state regulations and decisions are based on the Ethics committee. Unless the resident has frequent hospitalization s or a terminal [DIAGNOSES REDACTED]. The surveyor interviewed Licensed Practical Nurse (LPN#1) on [DATE] at 10:50 AM. LPN #1 stated that Resident #2 was a ward of the state and that he/she did not have a DNR/DNI status. LPN #1 further stated that Resident #2 expired at the facility on [DATE] at 8 PM. As per LPN #1, the Aide, (CNA #1) provided incontinence care for Resident #2 on [DATE] at 6 PM and more care was provided at 6:30 PM whereby the resident was arousable and everything was fine. At 8 PM CNA #1 came to the nurse and said Oh my God, he is gone. LPN #1 then proceeded to check the resident and observed that Resident #2 was cold, and Riga Mortis was setting in. LPN #1 checked Resident #2's vital signs and resident had no pulse, no breath sounds and no blood pressure. LPN #1 then called the Supervisor and reported that Resident #2 was found dead. The supervisor came to the unit about 5 to 10 minutes later and pronounced the resident at 8:10 PM. LPN #1 did not call a code, did not start CPR and did not call 911. The surveyor interviewed the RN #1 Supervisor on [DATE] at 1:55 PM. As per RN #1, I was called by the LPN (#1) around 8 PM that the patient died . I was on the second floor doing an admission. When I went to the unit, I looked at the patient and saw that he/she must have been dead for a while. (He/she) was cold and pasty. I asked when was the patient last seen and was told that the CNA (#1) saw the resident at 6:30 PM. The LPN (#1) did the vitals on the patient. I did not know the patient or if he/she was a full code. I did not ask if the patient was a full code. He/she was to be seen every two hours and was last seen at 6:30 PM. I did not document in the patients chart because the LPN said that she/he would document. I was in a hurry because I had to finish the new admission and I was doing the death certificate, so I forgot that the nurse was an LPN. I pronounced the resident at 8:10 or 8:15 PM but put it in as 8:10 PM because I did not want to show it took me a long time to come down to see the patient. Our policy is that if a patient is a full code, then 911 has to be called and we must do CPR. The paramedics would then pronounce when they arrived. I reviewed the chart at a later time and realized that the patient was not a DNR, and was a full code. They did not call a code on that day. Code seven should have been called and the AED should have been brought up, whether or not we could have saved him. Even if it was an hour later, we should have called 911 and started CPR. The LPN (#1) said that the patient was dead and not resusable. The mistake was on my part, I should have checked, but I relied on the nurse because I felt she knew the patient. In hindsight a code should have been called and we should have called 911 and started CPR. The surveyor interviewed the DON on [DATE] at 11:05 AM. During the interview, the DON stated that if a patient is found non-responsive and any change in condition is observed, then staff must page a code seven. The phones are in the hallways and at the nursing station. All nurses are to respond. The nurse on the first floor is to bring up emergency cart and the AED. CPR must be started and 911 should to be called. The surveyor interviewed RN #2 on [DATE] at 2:20 PM. According to RN #2, if they are informed of resident change in status, the RN must asses the patient's respirations, heart rate and blood pressure. There is a list of the DNR/DNH (Do Not Hospitalize) residents on the unit. Also the resident's arm band is blue to identify the residents who are DNR. The nurse has to call a code and the other nurses come from other floors. The nurse on the first floor brings up the AED. Somebody calls 911 and prepares the transfer papers. If the resident is still not responsive, will continue CPR until the paramedics arrive. CPR is always for residents with a full code status, even if the resident is pulseless and unresponsive. If the resident is determined to be really dead by the RN, then she would not start the CPR but the LPN would not be able to make that determination. The surveyor interviewed LPN #2 on [DATE] at 2:25 PM. As per LPN #2, Our policy is a code seven is called and we all respond. The nurse on the floor would direct me to the room. We bring the defibrillator, start CPR and call 911. We must check if the resident is unresponsive and check the arm band if the resident is DNR. If could not arouse the resident, or if have no pulse, no respirations we must start the CPR and call a code. If we don't know how long the resident is dead, we would start CPR, even if the resident is cold. As an LPN, I can not determine death. Even if I know CPR would not work, I would still do the CPR. The surveyor interviewed LPN #3 on [DATE] at 2:35 PM. According to LPN #3, if noticed that resident was unresponsive, would do an assessment and call a code. The LPN also stated that he/she would stay with the patient and start CPR. LPN #3 further stated, That is the protocol, that even if the patient is cold and pulseless, we have to start the CPR. Sometimes they (residents) come back. Anybody that we see unresponsive with no pulse and no breaths, we are supposed to start CPR. The surveyor interviewed CNA #1 on [DATE] at 2:45 PM. As per the CNA #1, she went to do PM care for the resident (#2), a little after 6 PM and then again at 7:55 PM. CNA #1 indicated that at 6 PM, Resident #2 was his usual self and that he did not appear to be weak and that he/she was breathing fine. At 7:55 PM she observed that Resident #2 was unresponsive and she called the LPN (#1). The nurse came right away and did vital signs and went to get the supervisor. I was with the resident until the supervisor and the nurse came back. CNA #1 was not able to remember the time that the LPN #1 and the RN #1 supervisor came back into the room. On [DATE] at 3:09 PM, the ADON stated that there was no quality of life in Resident #2 and that since they did not know how long the person may have been dead, he/she could have been brain dead. She further stated that CPR is not needed if you don't know how long the person was dead.We did not see him/her take the last breath so CPR was not needed. He may have been brain dead, so there is no quality of life. How many times did he need to be hospitalized ? five times, 10 times? The facility's failure to perform CPR according to the facility policy placed Resident #2 in an jeopardy situation, and the potential for all the residents who were not a DNR status, at risk for an immediate jeopardy (IJ) situation. The IJ was identified by the surveyor and reported to the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 3:09 PM. The IJ which began on [DATE] and was lifted on [DATE] at 5:08 PM when an acceptable plan of correction was implemented. as evidenced by the following: The plan states: 1. Resident (#2) expired and is no longer residing in the facility. 2. All residents in the facility that do not have a DNR, can potentially be effected. Residents can be identified by reviewing their POLST and/or advance directives and physician orders. 3. All licensed staff started to be educated regarding when to initiate CPR after a resident codes. The facilities (sig facility's) policy regarding CPR has been reviewed. The inservice will continue until all licensed staff have been educated. When the resident becomes unresponsive, CPR is to be initiated and 911 should be called. The DON or designee will ensure that all licensed staff have been in-serviced and re-educated starting [DATE]. 4. All licensed staff have started to be educated on the CPR policy. Five licensed staff will randomly be interviewed monthly regarding the CPR policy and when to initiate CPR by the Director of Nursing/designee. The results of these audits will be reported by the DON/designee to the LNHA/QA committee quarterly for one year and more often as needed. NJAC 8:,[DATE].1 B. Based on record review, policy and procedure review and staff interview it was determined that the facility nursing staff failed to correctly document if medications were or were not administered on the Medication Administration Record [REDACTED]. This deficient practice was evidenced by the following: The deficiency continues at a level D for the following deficiency: The surveyor observed that the MAR for Resident #2 contained nurses initials which were circled and the reason was not entered on the back of the MAR indicated [REDACTED]. According to the facility documentation, Resident #2 was present at the facility on [DATE] and expired on same date at 8 PM. 1. According to the Physician Order Sheet (POS) dated [DATE] for Resident #2, the following medications were to be administered: a. [MEDICATION NAME] Sulf 2.5 MG (milligrams)/ 3 ML (milliliters) vial. 1 vial via nebulizer every 6 hours for [MEDICAL CONDITIONS]. b. [MEDICATION NAME] Tab (tablet) 40 MG. 1 tablet (40 MG) via peg tube at bedtime [MEDICAL CONDITION](Gastro [MEDICAL CONDITION] Reflux Disease). c. [MEDICATION NAME] Sod Inj (injection) 5000/ML. Inject 1 ML (5,000 units) subcutaneously every 8 hours for [MEDICAL CONDITIONS] [MEDICATION NAME]. d. Levetiraceta Sol 100 Mg/ML. 5 MLS (500 MG) via peg tube every 12 hours for [MEDICAL CONDITION]. e. [MEDICATION NAME] Tab 10 MG. 1 tablet (10 MG) via peg tube every 8 hours for Orthostatic [MEDICAL CONDITION]. f. Misoprotol tab 100 MG. 1 tablet via peg tube every 6 hours for GERD. g. Multi-Delyn Liq (liquid). 5 MLS via [DEVICE] (gastric tube) daily for supplement. h. Potassium Chl 20 MEQ (Milliequivalent)/15 MLS. 15 MLS (20 MEQ) via peg tube daily for supplement. i. [MEDICATION NAME] 40 ML/HR (hour) x (times) 22 HRS via peg tube, start @ (at) 4 PM down at 2 PM. 2. Review of the MAR indicated [REDACTED] a. [MEDICATION NAME] Sulf 2.5 MG (milligrams)/ 3 ML (milliliters) vial. 1 vial via nebulizer every 6 hours for [MEDICAL CONDITIONS] was ordered. The MAR indicated [REDACTED]. According to the facility policy circling initials indicates that the medication was not administered and requires an explanation is to be written on the reverse side of the MAR. b. [MEDICATION NAME] Tab (tablet) 40 MG. 1 tablet (40 MG) via peg tube at bedtime [MEDICAL CONDITION](Gastro [MEDICAL CONDITION] Reflux Disease). The MAR indicated [REDACTED]. According to the facility policy circling initials indicates that the medication was not administered and requires an explanation is to be written on the reverse side of the MAR. c. [MEDICATION NAME] Sod Inj (injection) 5000/ML. Inject 1 ML (5,000 units) subcutaneously every 8 hours for [MEDICAL CONDITIONS] [MEDICATION NAME]. The MAR indicated [REDACTED]. According to the facility policy circling initials indicates that the medication was not administered and requires an explanation is to be written on the reverse side of the MAR. d. Levetiraceta Sol 100 Mg/ML. 5 MLS (500 MG) via peg tube every 12 hours for [MEDICAL CONDITION]. The MAR indicated [REDACTED]. According to the facility policy circling initials indicates that the medication was not administered and requires an explanation is to be written on the reverse side of the MAR. e. [MEDICATION NAME] Tab 10 MG. 1 tablet (10 MG) via peg tube every 8 hours for Orthostatic [MEDICAL CONDITION]. The MAR indicated [REDACTED]. According to the facility policy circling initials indicates that the medication was not administered and requires an explanation is to be written on the reverse side of the MAR. f. Misoprotol tab 100 MG. 1 tablet via peg tube every 6 hours for GERD. The MAR indicated [REDACTED]. According to the facility policy circling initials indicates that the medication was not administered and requires an explanation is to be written on the reverse side of the MAR. g. Multi-Delyn Liq (liquid). 5 MLS via [DEVICE] (gastric tube) daily for supplement. The MAR indicated [REDACTED]. According to the facility policy circling initials indicates that the medication was not administered and requires an explanation is to be written on the reverse side of the MAR. h. Potassium Chl 20 MEQ (Milliequivalent)/15 MLS. 15 MLS (20 MEQ) via peg tube daily for supplement. The MAR indicated [REDACTED]. According to the facility policy circling initials indicates that the medication was not administered and requires an explanation is to be written on the reverse side of the MAR. i. [MEDICATION NAME] 40 ML/HR (hour) x (times) 22 HRS via peg tube, start @ (at) 4 PM down at 2 PM. The MAR indicated [REDACTED]. According to the facility policy circling initials indicates that the [MEDICATION NAME] was not administered and requires an explanation is to be written on the reverse side of the MAR. The surveyor interviewed the DON on [DATE] at 11:05 AM. The DON stated that the facility policy indicated that if the nurse's initials for a medication is circled on the MAR, it means that it was not given. The surveyor interviewed the LPN #1 on [DATE] at 12:50 PM. The LPN #1 indicated that all the 4 PM, 5 PM and 6 PM medications were given but not the medications at 9 PM and 10 PM. I was a wreck that day. It (medication entry on the MAR) should be circled when not given, and the reason (for not given) should be written on the back of the MAR. A review of the facility policy for Charting of Medications dated [DATE], indicated the following: The Medication Administration Records (MAR) and the Treatment Administration Record (TAR) will accurately reflect the current Physician Orders and the individual residents needs. Procedure: Each medication/treatment will be signed for by the RN/LPN after it is successfully administered and/or completed. If a medication is withheld, refused or regurgitated, the RN/LPN initials for the medication dose in question is circled. An explanation is to be written on the reverse side of the MAR/TAR. NJAC 8:,[DATE].2(a)

Complaint #: NJ Based on interviews, review of medical records and facility documentation, it was determined that the facility staff failed to administer Cardio [MEDICAL CONDITION] Resuscitation (CPR) according to the Healthcare Provider Basic Life Support standards for 1 of 3 sampled residents (Resident #2) and according to the facility Full Code policy. According to Resident #2's chart, the resident did not have Advance Directives and was not a DNR/DNI (Do Not Resuscitate/Do Not Intubate). On [DATE] at 7:50 PM, Resident #2 was found with no pulse and no respirations. The facility staff failed to initiate CPR. At 8 PM, LPN #1 informed the Registered Nurse (RN) supervisor that Resident #2 was found dead. Resident #2 was pronounced by the RN supervisor at 8:10 PM. The facility's failure to perform CPR according to the facility policy placed Resident #2 in an jeopardy situation, and the potential for all the residents who were not a DNR status, at risk for an immediate jeopardy (IJ) situation. The IJ was identified by the surveyor and reported to the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 3:09 PM. The IJ which began on [DATE] and was lifted on [DATE] at 5:08 PM when an acceptable plan of correction was implemented. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated Title 45: ,[DATE] 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, .and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45: ,[DATE] The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities ., under the direction of a registered nurse or licensed or otherwise legally authorized physician. Reference: Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation an Emergency Cardiovascular Care. The American Heart Association states: Withholding and Withdrawing Referencing CPR (Termination of Resuscitative Efforts) Related to Out-of Hospital [MEDICAL CONDITION] (OHCA) Criteria for Not Starting CPR in All OHCA Basic life support (BLS) training urges all potential rescuers to immediately begin CPR without seeking consent, because any delay in care dramatically decreases the chances of survival. While the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION], there are a few exceptions where withholding CPR might be appropriate, as follows: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril, obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection or decomposition), a valid, signed and dated advance directive indicating that resuscitation is not desired, or a valid, signed and dated DNAR (do not attempt resuscitation) order. Reference:http: //www.nj.gov/health/advance directive/polst.shtml POLST Practitioner Orders for Life Sustaining Treatment .enable patients to indicate their preferences regarding life-sustaining treatment. The law calls for the creation of a standardized Practitioner Orders for Life Sustaining Treatment (POLST) form that is signed by a patient's attending physician or advanced practice nurse and provides instructions for health care personnel to follow for a range of life-prolonging interventions. This form becomes part of a patient's medical records, following the patient from one healthcare setting to another, including hospital, home, nursing home, or hospice. Review of the facility Full Code Policy dated [DATE] indicated the following: In the interest of preserving the dignity and quality of life of its patients, (Facility) honors full code requests. Procedure: 1) Upon admission the resident will be assessed regarding their code status. 2) In case of a medical emergency for these residents, the charge nurse will page CODE SEVEN. All PCC (Patient Care Coordinators) or charge nurses must respond to the location of emergency and the emergency cart will be brought in the patients location, CPR must be initiated, then 911 must be called and all appropriate measures taken. 3) All residents without a green printed armband will be considered full code status until deemed otherwise. Review of the facility Emergency Policy dated [DATE] indicated the following: Should an emergency situation occur involving one of the resident/employee, appropriate assistance is to be obtained immediately. Procedure: When an emergency situation occurs with a Resident/Employee, you are to follow these guidelines to obtain assistance: a) Someone must stay with the affected person. b) Go to the nearest phone and page CODE 7 and the area where the help is needed. According to the Admitting Face Sheet dated [DATE], Resident #2 was admitted to the facility in [DATE] with the [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), an assessment tool dated [DATE], indicated that Resident #2 was cognitively impaired. The MDS documentation included that the Resident required total staff assistance for Activities of daily Living (ADL's). A review of the New Jersey - Electronic Death Registration System indicated the date of death , [DATE]. Time of death, 8 PM. Place of death, Nursing Home/Long Term Care Facility. A review of the interdisciplinary progress note dated [DATE] indicated, Staff discussed options for the resident at this time in order to be as comfortable as possible with the resident's guardian. Guardian maintained she has to follow state regulations and decisions are based on the Ethics committee. Unless the resident has frequent hospitalization s or a terminal [DIAGNOSES REDACTED]. The surveyor interviewed Licensed Practical Nurse (LPN#1) on [DATE] at 10:50 AM. LPN #1 stated that Resident #2 was a ward of the state and that he/she did not have a DNR/DNI status. LPN #1 further stated that Resident #2 expired at the facility on [DATE] at 8 PM. As per LPN #1, the Aide, (CNA #1) provided incontinence care for Resident #2 on [DATE] at 6 PM and more care was provided at 6:30 PM whereby the resident was arousable and everything was fine. At 8 PM CNA #1 came to the nurse and said Oh my God, he is gone. LPN #1 then proceeded to check the resident and observed that Resident #2 was cold, and Riga Mortis was setting in. LPN #1 checked Resident #2's vital signs and resident had no pulse, no breath sounds and no blood pressure. LPN #1 then called the Supervisor and reported that Resident #2 was found dead. The supervisor came to the unit about 5 to 10 minutes later and pronounced the resident at 8:10 PM. LPN #1 did not call a code, did not start CPR and did not call 911. The surveyor interviewed the RN #1 Supervisor on [DATE] at 1:55 PM. As per RN #1, I was called by the LPN (#1) around 8 PM that the patient died . I was on the second floor doing an admission. When I went to the unit, I looked at the patient and saw that he/she must have been dead for a while. (He/she) was cold and pasty. I asked when was the patient last seen and was told that the CNA (#1) saw the resident at 6:30 PM. The LPN (#1) did the vitals on the patient. I did not know the patient or if he/she was a full code. I did not ask if the patient was a full code. He/she was to be seen every two hours and was last seen at 6:30 PM. I did not document in the patients chart because the LPN said that she/he would document. I was in a hurry because I had to finish the new admission and I was doing the death certificate, so I forgot that the nurse was an LPN. I pronounced the resident at 8:10 or 8:15 PM but put it in as 8:10 PM because I did not want to show it took me a long time to come down to see the patient. Our policy is that if a patient is a full code, then 911 has to be called and we must do CPR. The paramedics would then pronounce when they arrived. I reviewed the chart at a later time and realized that the patient was not a DNR, and was a full code. They did not call a code on that day. Code seven should have been called and the AED should have been brought up, whether or not we could have saved him. Even if it was an hour later, we should have called 911 and started CPR. The LPN (#1) said that the patient was dead and not resuscable. The mistake was on my part, I should have checked, but I relied on the nurse because I felt she knew the patient. In hindsight a code should have been called and we should have called 911 and started CPR. The surveyor interviewed the DON on [DATE] at 11:05 AM. During the interview, the DON stated that if a patient is found non-responsive and any change in condition is observed, then staff must page a code seven. The phones are in the hallways and at the nursing station. All nurses are to respond. The nurse on the first floor is to bring up emergency cart and the AED. CPR must be started and 911 should to be called. The surveyor interviewed RN #2 on [DATE] at 2:20 PM. According to RN #2, if they are informed of resident change in status, the RN must asses the patient's respirations, heart rate and blood pressure. There is a list of the DNR/DNH (Do Not Hospitalize) residents on the unit. Also the resident's arm band is blue to identify the residents who are DNR. The nurse has to call a code and the other nurses come from other floors. The nurse on the first floor brings up the AED. Somebody calls 911 and prepares the transfer papers. If the resident is still not responsive, will continue CPR until the paramedics arrive. CPR is always for residents with a full code status, even if the resident is pulseless and unresponsive. If the resident is determined to be really dead by the RN, then she would not start the CPR but the LPN would not be able to make that determination. The surveyor interviewed LPN #2 on [DATE] at 2:25 PM. As per LPN #2, Our policy is a code seven is called and we all respond. The nurse on the floor would direct me to the room. We bring the defibrillator, start CPR and call 911. We must check if the resident is unresponsive and check the arm band if the resident is DNR. If could not arouse the resident, or if have no pulse, no respirations we must start the CPR and call a code. If we don't know how long the resident is dead, we would start CPR, even if the resident is cold. As an LPN, I can not determine death. Even if I know CPR would not work, I would still do the CPR. The surveyor interviewed LPN #3 on [DATE] at 2:35 PM. According to LPN #3, if noticed that resident was unresponsive, would do an assessment and call a code. The LPN also stated that he/she would stay with the patient and start CPR. LPN #3 further stated, That is the protocol, that even if the patient is cold and pulseless, we have to start the CPR. Sometimes they (residents) come back. Anybody that we see unresponsive with no pulse and no breaths, we are supposed to start CPR. The surveyor interviewed CNA #1 on [DATE] at 2:45 PM. As per the CNA #1, she went to do PM care for the resident (#2), a little after 6 PM and then again at 7:55 PM. CNA #1 indicated that at 6 PM, Resident #2 was (his/her) usual self and did not appear to be weak and that (he/she) was breathing fine. At 7:55 PM she observed that Resident #2 was unresponsive and she called the LPN (#1). The nurse came right away and did vital signs and went to get the supervisor. I was with the resident until the supervisor and the nurse came back. CNA #1 was not able to remember the time that the LPN #1 and the RN #1 supervisor came back into the room. On [DATE] at 3:09 PM, the ADON stated that there was no quality of life in Resident #2 and that since they did not know how long the person may have been dead, he/she could have been brain dead. She further stated that CPR is not needed if you don't know how long the person was dead.We did not see him/her take the last breath so CPR was not needed. He/She may have been brain dead, so there is no quality of life. How many times did he need to be hospitalized ? five times, 10 times? The Immediate Jeopardy which began on [DATE] and was identified on [DATE], was lifted on [DATE] at 5:08 PM, as evidenced by the implementation of an acceptable plan of corrections as follows: 1. Resident (#2) expired and is no longer residing in the facility. 2. All residents in the facility that do not have a DNR, can potentially be effected. Residents can be identified by reviewing their POLST and/or advance directives and physician orders. 3. All licensed staff started to be educated regarding when to initiate CPR after a resident codes. The facilities (sig facility's) policy regarding CPR has been reviewed. The inservice will continue until all licensed staff have been educated. When the resident becomes unresponsive, CPR is to be initiated and 911 should be called. The DON or designee will ensure that all licensed staff have been in-serviced and re-educated starting [DATE]. 4. All licensed staff have started to be educated on the CPR policy. Five licensed staff will randomly be interviewed monthly regarding the CPR policy and when to initiate CPR by the Director of Nursing/designee. The results of these audits will be reported by the DON/designee to the LNHA/QA committee quarterly for one year and more often as needed. NJAC 8:,[DATE].1(b)