Every finding on record at Laurel Manor Healthcare and Rehabilitation Center

Complaint 2639643Based on medical record review and staff interviews, the facility failed to ensure that a physician order for oxygen was obtained upon a resident's admission. Specifically, the facility implemented and maintained oxygen therapy as part of a resident's Care Plan (CP) without a corresponding physician order to support its use. This deficient practice was identified for 1 of 6 residents reviewed (Resident #5).According to the admission Record (AR), Resident #5 was admitted to the facility with diagnoses which included but were not limited to: unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, unspecified fall, emphysema (chronic, progressive lung disease characterized by damage to the air sacs), and Chronic Obstructive Pulmonary Disease (COPD) (a progressive, chronic inflammatory lung disease that causes obstructed airflow, making it difficult to breathe).According to the discharge Minimum Data Set (MDS), an assessment tool dated 10/1/25, Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was cognitively intact.During the survey, the surveyor reviewed Resident #5's Order Summary Report (OSR) which did not include an order for oxygen although the resident CP and vitals indicated that Resident #5 was utilizing oxygen at the facility.Resident #5's CP included the following:Under Focus date initiated 9/25/25: [Resident #5] has Oxygen Therapy r/t COPD 3LPM (3 Liters Per Minute) via nasal cannula continuously. Under Interventions: Monitor for s/sx (Signs/Symptoms) of respiratory distress and report to MD (Medical Director) PRN (as needed): Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis (excessive, generalized sweating unrelated to heat or exercise), Headaches, Lethargy, Confusion, Atelectasis (the partial or complete collapse of lung tissue (alveoli) resulting in reduced, inefficient gas exchange), Hemoptysis (the coughing up of blood or blood-stained mucus from the lower respiratory tract, often caused by infections or cancer), Cough, Pleuritic pain (a sudden, sharp, or stabbing pain that worsens when breathing, coughing, or sneezing, caused by inflammation of the pleura (lung lining)), Accessory muscle usage, Skin color.On 4/10/26 at 9:09 AM, the surveyor interviewed the LPN who stated that when a resident is admitted from the hospital to the facility the LPNs will take vitals and the Unit Manager (UM) or the Registered Nurse (RN) will do the resident's assessment. He stated that the facility will transcribe and review orders with the physician for the facility. The LPN stated that if a resident is on oxygen, they should have a physician order for the oxygen. The LPN further stated that the supervisor or UM, whoever the RN is, usually transcribes the orders.On 4/10/26 at 9:23 AM, the surveyor interviewed a UM who stated that if a resident is on oxygen they should have an order and be care planned for the oxygen. The UM further stated that the night shift does chart checks, and they make sure the orders are carried out.On 4/10/26 at 9:30 AM, the surveyor showed the UM Resident #5's CP and OSR and requested the UM to locate an order for oxygen. UM confirmed there was no order for oxygen but that there was a CP for it. She stated there should have been a physician order for oxygen for Resident #5.On 4/10/26 at 9:51 AM, the surveyor interviewed the RN for the Upper [NAME] unit of the facility. The RN stated that there is a 3-step chart check where the admission nurse, the UM and the Director of Nursing (DON) check the chart. The RN further stated that the night shift also checks and that someone should have caught that there was not an oxygen order.The surveyor showed the RN Resident #5's CP and OSR and requested the RN to locate an order for oxygen. The RN was unable to find a physician order for oxygen. The RN stated Resident #5 should have had a physician order for their oxygen.On 4/10/26 at 10:06 AM, the surveyor interviewed the DON. The surveyor showed the DON Resident #5's CP and OSR and requested the DON to locate an order for oxygen. The DON confirmed there was not an order for Resident #5's oxygen and stated there should be. She further stated the order for oxygen should match a resident's CP.A review of the facility's policy titled, Physician Orders with a reviewed date of 10/2025, included the following information under Policy: To define a process for transcribing Orders directly from physicians, and nurse practitioners. Under, Procedures: 4. Process for accepting verbally communicated orders: a. The listener will transcribe the complete order to PCC under the patient's chart. b. Read the transcribed order back to the provider to ensure the listener has properly heard and understood the communication. 5. All verbal or written orders must be signed by the prescriber monthly.NJAC 8:39-11.2(a)

Based on observation, interview, and record review, the facility failed to assess the risk of entrapment, try alternatives, and/or obtain informed consent before initiating side rails for seven (Residents (R)1, R11, R83, and R87) of seven residents reviewed for side rails. These failures could result in serious injury or death to residents. Findings include: Review of the facility policy titled Side Rail, dated 12/24, provided by the facility revealed It is the policy of this facility to provide residents with side rails as an enabler for bed mobility. Procedure: 1. Upon admission, the nurse will assess the need for side rails using the Side Rail Assessment form in [Electronic Medical Record software]. 2. Side rails will be monitored and re-evaluated on a quarterly basis (based on MDS [Minimum Data Set] schedule) or as warranted by the resident's condition. 3. Residents may request the use of side rails for their own personal reasons. It is the resident's right that this decision must be honored. 4. If resident's family requests side rail use, the nurse will assess the resident and the request, discuss risks involved with its use with the resident and family and describe alternative individualized care practices (i.e. a lower bed) that may be safer and appropriate for the resident. 1. Review of R11's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including muscle weakness and abnormalities of gait and mobility. Review of R11's significant change Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/07/25, revealed she scored five out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of R11's Care Plan, located under the Care Plan tab of the EMR dated 10/25/23, revealed The resident used side rails as an enabler. Interventions in place were to use side rails for turning and repositioning. Further review no updates to care plan since 10/25/23.Review of R11's Physician Orders, located under the Orders tab in the EMR, dated 07/11/23, revealed .bilateral quarter side rails used as an enabler. Review of R11's Resident Evaluation/Bedrail Assist Device, located under the Observations tab in the EMR and dated 01/17/25, 04/23/25 and 07/22/25, revealed no evidence of alternates explored, or risk versus benefits. During an interview on 08/27/25 at 2:15 PM Registered Nurse/Unit Manager (RN/UM) 1 stated residents were assessed for side rails on admission, and they were asked if they wanted side rails. She said she thought that risks and benefits were discussed but she was unsure where these signed consents were located or if they explored alternates prior to use. During an interview on 08/27/25 at 2:27 PM Licensed Practical Nurse/Unit Manager (LPN/UM)1 said staff were not exploring alternatives prior to using bedrails for residents. She also stated they do not discuss risk versus benefits with residents, but they did inform them bedrails were considered a restraint and ask them if they wanted them or not. During an interview on 08/28/25 at 8:57 AM the Director of Nursing (DON) said staff would ask for verbal consent for side rail use upon admission but it was not documented. She said the nurse would discuss risk versus benefits, but it was not documented. She said staff asked residents if they wanted side rails and they would be provided at that time. She was unaware of alternates were explored prior to use. 2. Observations on 08/25/25 at 2:00 PM, 08/27/25 at 10:00 AM, and 08/28/25 at 1:30 PM revealed R6 laying on his bed with both half siderails in the raised position. Review of R6's Electronic Medical Record (EMR) under the Clinical Census tab revealed he had been admitted on [DATE] at 9:15 PM. Review of R6's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/03/25 under the MDS tab revealed his Brief Interview for Mental Status (BIMS) score was 0 out of 15. This indicated he had severe cognitive impairment. Review of R6's Admission/readmission Evaluation found under the Assessment tab completed on 06/03/25 revealed the side rail assessment section. This assessment revealed he had an alteration in safety awareness due to his cognitive decline, he had a history of falls, he had poor bed mobility or had difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, was on medications that required increased safety precautions, was currently using the side rail for positioning or support, and he expressed his desire for the siderails. The interventions checked included: lower the bed to the floor, provide restorative care to enhance abilities to stand, transfer, and walk safely, provide frequent staff monitoring at night, periodic assisted toileting for resident at night, and visual and verbal reminders to use the call bell. Recommendations included the use of bilateral half side rails. 3. Observations on 08/25/25 at 1:45 PM revealed R87 was laying in her bed with her bilateral half siderails in the raised position. Review of R87's (EMR) under the Clinical Census tab revealed she had been admitted on [DATE]. Review of R87's admission MDS with an ARD of 08/14/25 under the MDS tab revealed her BIMS score was 0 out of 15. This indicated she had severe cognitive impairment. Review of R87's Admission/readmission Evaluation found under the Assessment tab completed on 08/08/25 revealed the side rail assessment section. This assessment revealed she had an alteration in safety awareness due to her cognitive decline, she had a history of falls, she had poor bed mobility or had difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, was on medications that required increased safety precautions, and was currently using the side rail for positioning or support. The interventions checked included: provide restorative care to enhance abilities to stand, transfer, and walk safely, provide frequent staff monitoring at night, periodic assisted toileting for resident at night, and visual and verbal reminders to use the call bell. Recommendations included the use of bilateral half side rails. Interview on 08/27/25 at 10:48 AM with RN-UM1 said the DON does the review of the care plan. She said all the beds had side rails attached to them. She said if the resident did not need the side rails they were just left down. She agreed most of the residents had side rails on their beds, including R6 and R87. 4. Review of R1's quarterly MDS with an ARD date of 08/01/25, located in the MDS tab of the EMR, revealed an admission date of 01/23/23, a BIMS score of 11 out of 15, indicating R1's cognition was moderately impaired, and had a diagnosis of seizure, gastrostomy status, and acute respiratory failure with hypoxia. Review of R1's Orders, located in the EMR under the Order tab revealed no order for side rails. Review of R1's Care Plan, dated 07/09/24, located in the EMR under the Care Plan tab revealed R1 use side rails as an enabler. Interventions included Discuss and record, with the resident/family the risk and benefits of side rails, Ensure valid consent on Chart prior to initiating siderails, and Evaluate the resident use of siderails and continuing risk/benefits and the need for ongoing use upon admission, significant changes, annually and quarterly. Review of R1's admission evaluation, dated 01/23/23, located in the EMR under the Assessment tab revealed no side rail assessment or consent for side rails. Review of R1's siderail assessment, dated 05/08/25, located in the EMR under the Assessment tab revealed R1's was a high risk for fall but the assessment did not include the risk of entrapment or if informed consent was obtained. The assessment was completed by Corporate Registered Nurse (CRN). During an interview on 08/27/25 at 9:19 AM, LPN2 was asked why R1 had side rails on his bed. LPN2 stated, I can't answer that question. During an interview on 08/27/25 at 10:47 AM, the DON was asked why R1 had side rails on his bed. DON stated they were used as enablers and R1 could use them. DON stated side rail assessments were completed quarterly. DON was asked where the informed consent would be documented. DON stated there are no written consents, only verbal, which was obtained during admission. DON stated she was working on a written informed consent form. During an interview on 08/27/25 at 12:36 PM, Certified Nurse Aide-Agency (CNA - A)5 was asked if she was R1's nurse aide and CNA-A5 stated, Yes. CNA-A5 was asked why R1 had side rails on his bed. CNA-A5 stated she was agency, and she didn't know why, and she didn't know what the facility policy was concerning side rails. CNA-A5 went on to say she was the wrong person to ask about it. During a follow up interview on 08/28/25 at 10:00 AM, the DON was asked about R1's side rail assessment not addressing the risk of entrapment and risk verses benefits as R1 had a seizure diagnosis and cognition impairment. DON stated again that only verbal consent was obtained. DON asked why the entrapment or risk verse benefits were not in the assessments at admission or the 05/08/25 assessment. DON acknowledged the risk of entrapment and risk verses benefits were not documented. DON confirmed the facility's side rail policy didn't include risk of entrapment, risk verses benefits and informed consent. On 08/28/25 at 11:14 AM, R1 was awake in bed with his gastrostomy feeding in progress while watching television and side rails in the up position. R1 was asked if he could use his side rails to move himself in bed. R1 stated, Not too good. During an interview on 08/28/25 at 4:33 PM, CRN was asked if she completed R1's 05/08/25 side rail assessment. CRN stated, Yes. CRN was asked about the assessment not addressing the risk of entrapment in the document and if she was aware of the requirement. CRN confirmed the risk of entrapment was not in the assessment and was not aware of the requirement. CRN stated a section could be added. NJAC 8:39-27.1(a)

Based on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed after admission for one resident (Resident (R) 110 out of 24 sampled residents.Findings include:Review of R110's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R8 admitted to the facility on [DATE] with diagnoses including bipolar disorder, and anxiety disorder. Review of R110's NJ [New Jersey] Department of Human Services Pre-admission Screening and Resident Review (PASRR) Level I screen, dated 08/21/25 and located in the resident's EMR under the Miscellaneous tab, revealed no indication of mental illness identified. During an interview on 08/27/25 at 2:40 PM the Social Services Director (SSD) said she was not aware that R10 PASARR level I was not completed correctly. She stated that staff are usually looking for diagnosis like bipolar and schizophrenia but agreed that any mental illness diagnosis should be listed on the level I. During an interview on 08/28/25 at 8:57 AM the Director of nursing stated she expected staff to complete all assessments accurately and correctly. NJAC 8:39-5.1(a)

Based on record review, interviews, and policy review, the facility failed to ensure five of five newly admitted residents (Residents (R)6, R57, R87, R105, and R108) had documentation the Baseline Care Plan had been reviewed with the resident and/or representative within 48 hours, and a copy of the Care Plan had been offered. Findings Include: Review of the facility's policy titled, Care Plans - Comprehensive revised June 2025 indicated: The resident's baseline care plan is developed within 24-48 hours through the admission assessment. There was no procedure of the resident and/or their representative involvement with the baseline care plan. 1. Review of R6's Electronic Medical Record (EMR) under the Clinical Census tab revealed he had been admitted on [DATE]. Review of R6's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/03/25 under the MDS tab revealed his Brief Interview for Mental Status (BIMS) score was 0 out of 15 which indicated he had severe cognitive impairment. Review of R6's Admission/readmission Evaluation found under the Assessment tab revealed his Base Line Care Plan was completed on 06/04/25. There was no documentation the Care Plan had been reviewed with his representative. Review of R6's Social Services Admission/readmission Evaluation found under the Assessments tab completed on 06/06/25 revealed his representative did not participate in the assessment. Telephone interview on 08/28/25 at 1:40 PM with Family Member (FM)1 revealed she did not remember when the care plan had been reviewed. She was not offered a copy of the care plan. 2. Review of R87's EMR under the Clinical Census tab revealed she had been admitted on [DATE]. Review of R87's admission MDS with an ARD of 08/14/25 under the MDS tab revealed her BIMS score was 0 out of 15. This indicated she had severe cognitive impairment. Review of R87's Admission/readmission Evaluation found under the Assessment tab revealed her Base Line Care Plan was completed on 08/11/25. There was no documentation the Care Plan had been reviewed with his representative. 3. Review of R105's EMR under the Clinical Census tab revealed she had been admitted on [DATE]. Review of R105's EMR Social Service Admission/readmission Evaluation under the Assessments tab was completed on 08/20/25 the evaluation indicate a BIMS was completed, and her score was five out of 15 which indicated severe cognitive impairment. Review of R105's Admission/readmission Evaluation found under the Assessment tab revealed her Base Line Care Plan was completed on 06/04/25. There was no documentation the baseline Care Plan had been reviewed with her representative. Interview on 08/27/25 at 4:50 PM with the Director of Nursing (DON) revealed when a resident was admitted the admission assessment was completed by the nurse, an initial care plan was generated. She stated there was no documentation the resident and/or representative reviewed the initial care plan and was offered a copy within 48 hours of admission. 4. Review of R57's admission Record, located in the Profile tab of the EMR revealed admission to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, chronic kidney disease, hypertension and diverticulosis. Review of R57's admission MDS under the MDS tab of the EMR, with an ARD of 08/06/25 revealed the BIMS, revealed a score of 11 out of 15, which indicated moderately impaired cognition. This MDS assessment further indicated R57 required substantial/maximal assistance with toileting hygiene, bathing, and lower body dressing. Review of the EMR revealed no documentation in the medical record that the baseline care plan, developed upon admission, had been provided or reviewed with R57. Interview with R57 during initial rounds on 08/25/25 at 1:35PM, R57 stated she had not attended a care planning meeting or discussed her care with staff. 5. Review of R108's admission Record, located in the Profile tab of the EMR revealed admission to the facility on [DATE] with diagnoses of type 2diabetes mellitus, hypertension, bacteremia, and cellulitis of left lower limb. Review of R108's admission MDS under the MDS tab of the EMR, with an ARD of 08/06/25 revealed the BIMS, revealed a score of 15 out of 15, indicating intact cognition. Further review of the same MDS assessment revealed R108 required substantial/maximal assistance with toileting hygiene, bathing, lower body dressing and was dependent on staff for putting on/taking off his footwear. Review of the Electronic Medical Record (EMR) revealed no documentation in the medical record that the initial baseline care plan, developed upon admission, had been provided or reviewed with R108. Interview with R108 on 08/28/25 at 4:10PM revealed that he had not attended a Care Plan meeting or discussed his care with staff. NJAC 8:39-11.1NJAC 8:39-11.2

Based on observation, interview, record review, and policy review, the facility failed to follow physician orders to hold medication when blood pressure was outside of the parameters for two of two residents (Residents (R)1 and R8) reviewed for medications and ensure the appropriate use of a wander guard device for one of two residents (R11) reviewed for wandering. These failures had the potential to cause residents' conditions to exacerbate and affect quality of care.Findings include: Review of the facility's policy titled Medication Administration, reviewed 06/25It is the policy and procedure of the facility to provide the nursing staff with anunderstanding of proper medication administration. 1. Hold parameters: Check blood pressure and/or pulse rate immediately prior to pouring. Review of the facility policy titled, Wander Guard, revised 11/2021 revealed, it is the policy and procedure of this facility to provide a safe environment for its residents should a resident be identified as a wanderer. A wander guard will be applied for a resident with wandering potential upon admission or as needed based on assessment. 1. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 08/01/25, located in the MDS tab of the electronic medication record (EMR), revealed an admission date of 01/23/23, a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R1's cognition was moderately impaired, and had a diagnosis of orthostatic hypotension, gastrostomy status, and acute respiratory failure with hypoxia. Review of R1's Orders, dated 07/19/24, located in the EMR under the Order tab revealed Midodrine HCl Oral Tablet 5 MG [milligram] (Midodrine HCl), Give 1 tablet via PEG [percutaneous endoscopic gastrostomy]-Tube three times a day for hypotension monitor b/p [blood pressure] weekly. hold for SBP [systolic blood pressure] greater than 120. Review of R1's Care Plan, located in the EMR under the Care Plan tab revealed no care plan for hypotension or treatment. Review of Medical Clinician Progress Note, dated 04/06/25, located in the EMR under the Progress Note tab revealed Pt [patient] seen and examined lying in bed this AM sleeping, opens eyes to voice and is pleasant and cooperative. He reports feeling dizzy, BP reviewed and stable. He has a standing order of midodrine. Review of R1's August 2025 Medication Administration Record (MAR) located in the EMR under the Order tab revealed Midodrine was administered when R1's SBP was greater than 120. This included:On 08/02/25 at 9:00 AM, blood pressure measured 122/78On 08/13/25 at 1:00 PM, blood pressure measured 139/69On 08/15/25 at 9:00 AM, blood pressure measured 134/78On 08/15/25 at 1:00 PM, blood pressure measured 134/78 Review of R1's July 2025 MAR located in the EMR under the Order revealed Midodrine was administered when R1's SBP was greater than 120. This included:On 07/03/25 at 1:00 PM, blood pressure measured 124/82On 07/04/25 at 5:00 PM, blood pressure measured 128/79 Review of R1's June 2025 MAR located in the EMR under the Order revealed Midodrine was administered when R1's SBP was greater than 120. This included:On 06/02/25 at 9:00 AM, blood pressure measured 134/79On 06/02/25 at 1:00 PM, blood pressure measured 130/76On 06/11/25 at 1:00 PM, blood pressure measured 122/74On 06/16/25 at 1:00 PM, blood pressure measured 124/76 Review of R1's Pharmacist Recommendations, dated 01/11/25, 02/06/25, 03/11/25, 04/05/25, 05/06/25, 06/05/25, 07/14/25, and 08/07/25, provided by the facility, revealed Medication error(s) noted. Midodrine is not always held as required by the physician's hold order. Please review and follow the physician's order. During an interview on 08/27/25 at 12:28 PM, the Director of Nursing (DON) was asked about R1's physician order for Midodrine and if she was aware R1's Midodrine wasn't always held when his SBP was greater than 120 per the July 2025 and August 2025 MAR. DON stated she was aware. DON went on to say, it's been an ongoing education with staff. DON stated staff have been counseled, reprimanded and more education has been provided to staff about the importance of following the physician's order to hold his medication when his blood pressure was outside of the parameters. DON stated the situation has improved and there has been no negative outcome for R1. During a telephone interview on 08/28/25 at 10:22 AM, the Consulting Pharmacist (C.Rx) was asked about R1's Midodrine and should the nurses hold Midodrine if R1's SBP was greater than 120. The C.Rx stated, Yes. C.Rx was asked what could happen if the medication was not held when R1's SBP is greater than 120. C.Rx stated, there is no negative effects because his current blood pressure isn't too off. C.Rx went on to say, if it was, we might see headaches, hypertensive effects. C.Rx stated she has addressed the issue of not holding Midodrine in her monthly reviews. C.Rx stated the facility needs to educate their staff. 2. Review of R8's annual MDS with an ARD date of 07/30/25, located in the MDS tab of the EMR, revealed an admission date of 07/14/19, a BIMS score of 15 out of 15, indicating R8's cognition was intact, and had a diagnosis of hypertension, heart failure, and diabetes mellitus. Review of R8's Care Plan, dated 03/26/24, located in the EMR under the Care Plan tab revealed [R8] have [sic] HTN [hypertension]. Interventions included Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness and Obtain blood pressure readings as ordered. Take blood pressure readings under the same conditions each time. Review of R8's Orders, revised 05/14/25, located in the EMR under the Order tab revealed Hydralazine HCl Oral Tablet 25 MG (Hydralazine HCl), Give 1 tablet by mouth every 8 hours for HTN hold for sbp less than 120. Review of R8's August 2025 MAR, located in the EMR under the Order tab revealed Hydralazine was administered when R8's SBP was less than 120. This included:On 08/01/25 at 2:00 PM, blood pressure measured 108/55On 08/08/25 at 2:00 PM, blood pressure measured 115/66 Review of R8's July 2025 MAR, located in the EMR under the Order tab revealed Hydralazine was administered when R8's SBP was less than 120. This included: On 07/06/25 at 2:00 PM, blood pressure measured 104/42On 07/11/25 at 2:00 PM, blood pressure measured 116/51On 07/28/25 at 2:00 PM, blood pressure measured 116/73 Review of R8's June 2025 MAR, located in the EMR under the Order tab revealed Hydralazine was administered when R8's SBP was less than 120. This included:On 06/02/25 at 2:000, blood pressure measured 118/72On 06/21/25 at 2:00, blood pressure measured 110/50 Review of R8's Pharmacy Recommendations, dated 01/11/25, 06/05/25, 07/14/25, and 08/07/25, provided by the facility, revealed Medication error(s) noted. Hydralazine is not always held as required by the physician's hold order. Please review and follow the physician's order. During an interview on 08/27/25 at 12:28 PM, the DON was asked about R8's physician's order for hydralazine and if she was aware R8's hydralazine wasn't always help when her SBP was less than 120. DON stated she was aware. DON went on to say, it's been an ongoing education with staff and staff have been counseled, and more education has been provided to staff. DON stated the situation has improved and R8 has had no negative outcome because of her medication not held when her blood pressure was outside of parameters. On 08/27/25 at 4:08 PM, R8's was awake in bed, dressed and groomed. R8 was asked if she was aware of any time she was given her blood pressure medication when her blood pressure was too low. R8 stated she didn't think so. During a telephone interview on 08/28/25 at 10:30 AM, C.Rx was asked about R8's Hydralazine and should the nurses hold the medication if R8's SBP was less than 120. C.Rx stated, Yes. C.Rx was asked what could happen if Hydralazine was not held and R8's SBP was less than 120. CP.Rx stated there would be no negative effects with her because R8's blood pressure reading isn't too out of range. C.Rx went on to say, but if it was 90 it could cause hypotensive effects, but no negative effects so far. C.Rx stated staff need education and they have been doing better. 3. Review of R11's admission Record located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses including muscle weakness and abnormalities of gait and mobility. Review of R11's significant change MDS assessment under the MDS tab of the EMR, with an ARD of 08/07/25, revealed she scored five out of 15 on the BIMS, indicating severe cognitive impairment. Further review revealed no wandering behavior was exhibited. Review of R11's Care Plan, located under the Care Plan tab of the EMR dated 10/29/23, revealed The resident was care planned for risk for elopement and wears a wander guard. Interventions in place were to place wander guard on resident. Further review no updates to care plan since 10/29/23. Review of R11's Physician Orders, located under the Orders tab in the EMR dated 11/08/23 revealed wander guard for elopement prevention. Review of R11's Elopement Risk Assessment located under the Observations tab in the EMR dated 01/17/25, 04/23/25 and 07/22/25 revealed R11 was not at risk for elopement.Review of R7's General Notes, located under the Notes tab of the EMR, dated 03/27/25 through 08/27/25, revealed no documentation of any wandering or exit seeking behaviors. During an interview on 08/27/25 at 2:01 PM Certified Nurse Aide (CNA)3 said R11 like to attend activities regularly and enjoy coloring. R11 can propel herself up and down the hallway but has never been exit seeking and is not a wanderer. She stated R11 knows where she is going and goes there. During an interview on 08/27/25 at 2:15 PM Registered Nurse/Unit Manager (RN/UM) said R11 really enjoyed attending activities and likes bingo. She was able to self-propel throughout the facility and was aware of where her room was and what floor her room was located on. She has never personally seen her exit seeking or making threats to leave. She also stated if a resident was assessed to not be an elopement risk they should not have a wander guard. During an interview on 08/28/25 at 8:57 AM the Director of Nursing (DON) stated if a resident was assessed not to be an elopement risk they should not have a wander guard. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of four errors occurred out of 25 opportunities for error for two of five residents (Resident (R) 82, and R 108) observed for medication administration. The facility's medication error rate was 16%. The findings include: Review of the Medication Administration Policy reviewed date 06/2025 revealed under Policy, It is the policy and procedure of the facility to provide the nursing staff with an understanding of proper medical administration .Under Medication Timing item 2. revealed Medication ordered with food may be administered with milk and graham crackers (or similar items). 3. Medication ordered with meals should be given with the meal (i.e. Metoprolol). 4. Medication ordered before a meal should be specific to manufacturer's recommendation and administered prior to the start of the meal.). 1.Review of R82's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and hypertension. Review of R82's admission Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/01/25 revealed the Brief Interview for Mental Status (BIMS), revealed a score of 11 out of 15, which indicated moderately impaired cognition. Observation of Licensed Practical Nurse (LPN) 7 on 08/27/25 at 7:50 AM revealed LPN7 prepared R82's medication and placed one Amox-Clav 875-125 (Amoxicillin/Potassium Clavulanate) tablet, and Metoprolol Succinate ER 25mg 1/2 tablet in a small plastic medication cup. LPN7 then moved toward R82 and administered the medication. The medications were administered without the offer of food and before R82 had his breakfast meal. Review of the Physician's Orders in the EMR under the Orders tab revealed R82 was prescribed Amoxicillin/Potassium Clavulanate one tablet every twelve hours, to be given with food or meals for the treatment of Emphyema [sic]. Further review of the physician's orders revealed Metoprolol Succinate Extended Release (ER) was to be administered with meals for the treatment of hypertension. Interview with LPN 7 at the time of observation confirmed that she should have administered the medication with his breakfast meal. 2. Review of R108's admission Record, located in the Profile tab of the EMR revealed admission to the facility on [DATE] with diagnoses of type 2 diabetes mellitus. Review of R108's admission (MDS) under the MDS tab of the EMR, with an ARD of 08/06/25 revealed the BIMS, revealed a score of 15 out of 15, indicating intact cognition. Observation on 08/27/25 at 8:38 AM revealed LPN7 prepared R108's Metformin one 500miligram (mg) tablet and placed in a plastic medication cup. In addition, LPN7 prepared insulin from a vial of Insulin Lispro Injection Solution. LPN7 then drew eight units, the correct dosage of insulin and administered the insulin to R108 after he had consumed his breakfast meal. Interview with LPN7 at the time of observation confirmed that she should have administered the insulin prior to the resident eating his breakfast meal. Review of the Physician's Orders in the EMR under the Orders tab revealed R108 was prescribed Metformin one 500mg tablet twice a day, to be given with meals. Further review of the physician's orders revealed Insulin Lispro Injection Solution eight units were to be administered before meals for the treatment of Type 2 Diabetes Mellitus. Observation of the R108 at the time of observation revealed the resident had finished eating his breakfast in his room prior to the medication being administered, as evidence by an empty food tray. R108 confirmed he had eaten his breakfast and commented it was very good. Interview with Consulting Pharmacist (C. Rx) on 08/28/25 at 10:39 AM revealed administration of medications should be administered as ordered by the prescribing physician. The C. Rx further stated that the prescribing physician should be notified of medication discrepancies. Interview with the Director of Nursing (DON) on 08/28/25 at 10:00AM revealed that the facility expectation is that medications are to be administered as prescribed by the attending physician. NJAC 8:39-29.2(d)

Based on observation, interview, record review, and policy review, the facility failed to ensure one of one Resident (R)105 with a tracheostomy, corrugated respiratory tubing which delivered humidified oxygen, and a moisture collection bag had been kept off of the floor. Having the tubing and collection bag on the floor put R105 at risk of infection.Findings include: Review of the facility's policy titled, Oxygen Tubing and Respiratory Products revised October 2024 indicated, All oxygen tubing would have been properly stored to prevent the transmission of infection. If the tubing falls on the floor, it shall immediately be discarded and replaced to prevent contamination. Review of R105's Electronic Medical Record (EMR) Census List under the tab Census revealed she had been admitted on [DATE]. Review of R105's EMR Medical Diagnosis under the tab Medical Diagnosis revealed she had been admitted with a fracture of the base of her skull, epidural hemorrhage, chronic obstructive pulmonary disease, and previous acute respiratory failure which resulted in a tracheostomy. Review of R105's EMR Social Service Admission/readmission Evaluation under the Assessments tab was completed on 08/20/25. A Brief Interview for Mental Status was completed, and her score was five out of 15 which indicated severe cognitive impairment. Review of R105's EMR Care Plan under the Care Plan tab revealed focus area of her tracheostomy related to ineffective airway clearance. Her goals included R105 will have no s/sx [signs and/or symptoms] of infection through the review date. Interventions included Perform tracheostomy care every shift and Give humidified oxygen as prescribed. Observations on 08/25/2025 at 11:01 AM, on 08/26/25 at 1:15 PM, and on 08/27/25 at 9:25 AM revealed R105's corrugated humidified oxygen tubing with a moisture collection bag between two pieces of the tubing was laying on the floor beside her bed. She was laying in her bed. Interview on 08/25/25 at 4:00 PM with the Director of Nursing (DON) revealed R105 has a tracheostomy and uses a humidified oxygen delivery system. She said the corrugated respiratory tubing is changed daily on the night shift. Interview on 08/27/25 at 9:35 AM with Licensed Practical Nurse (LPN)3 revealed she has had training on tracheostomy care previously by the DON. She had a refresher on the care this morning by Registered Nurse/Unit Manager (RN UM)1. Observation and interview on 08/27/25 at 4:45 PM with LPN3 revealed the tubing for R105 was on the floor with the moisture collection bag also on the floor. She agreed the tubing being on the floor was an opportunity for infection. She said that they had not found a way to keep the tubing off the floor as it frequently was found laying on the floor. Interview on 08/28/25 at 9:00 AM with the DON revealed she had not been aware R105's corrugated humidified oxygen delivery system was laying on the floor. She agreed there was a chance for transmission of an infectious process. She agreed a system to keep it off of the floor should have been investigated sooner. NJAC 8:39-19.4

Complaint #: NJ171256 Based on observation, interview, record review and pertinent facility documents, it was determined that the facility failed to ensure the accountability of controlled substance inventories were completed in accordance with the facility's policy. This deficient practice was identified on 2 of 5 medication carts reviewed ( Lower [NAME] medication cart #3 and Redwood medication cart #2) during the medication storage and labeling task. The evidence was as followed: On 04/04/2024 at 10:51 AM, during an interview with the surveyor, Licensed Practical Nurse (LPN #1) stated that when the pharmacy brought in the controlled substances (drug or other substance that is tightly controlled by the government because it may be abused or cause addiction), both the incoming and outgoing nurses should sign the Controlled Substance Inventory Record (CSIR) and count the actual medication cards. LPN # 1 also confirmed that the CSIR should not be missing any documentation signatures. At that time, the surveyor, in the presence of LPN # 1, reviewed the Lower [NAME] medication cart #3 document titled, Controlled Substance Inventory Record which revealed the following: On 04/03/2024 in the section labeled, 7PM OUT: there was no signature. On 04/04/2024 at 12:08 PM, in the presence of the surveyor, LPN #2 counted the controlled substances in the Redwood medication cart #2. At that time, the surveyor compared the nurses audible count to the document titled, Individual Patient Controlled Substance Administration Record - 90 Dose specifically for the medication called Tramadol HCL 50 milligrams (mg) tablets (a medication used to treat pain). At that time, LPN #2 counted 74 tablets of Tramadol. The Individual Patient Controlled Substance Administration Record - 90 Dose document revealed a count of 75 tablets of Tramadol. LPN #2 then stated she administered the Tramadol tablet to a resident but forgot to sign the Individual Patient Controlled Substance Administration Record - 90 Dose document. On the same date and time, the surveyor compared the nurse's count to the document titled, Individual Patient Controlled Substance Administration Record - 60 Dose for Pregabalin capsule 75mg (medication used to treat nerve and muscle pain). At that time, LPN #2 counted 51 capsules. The Individual Patient Controlled Substance Administration Record - 60 Dose document revealed a count of 52 capsules of Pregabalin. LPN # 3 then stated she administered the Pregabalin capsule to a resident but forgot to sign the Individual Patient Controlled Substance Administration Record - 60 Dose document. On 04/05/2024 at 09:37 AM, during an interview with the surveyor, the Director of Nursing (DON) stated the unit manager and herself monitored the controlled substances. She further stated the purpose was to ensure it was being done and the counts were correct with no missing items. The DON confirmed the nurses should have signed the declining inventory logs as soon as the medication was dispensed. The DON acknowledged that the controlled substance inventory documents should not be missing signatures. A review of the of the facility's policy dated 01/2024 titled, Narcotic and Controlled Substance Policy and Procedure under the subsection, Procedure revealed but was not limited to, 3. A Narcotic Count will be completed by two Licensed Nurses prior to the end of each shift, opening of a unit and closing of a unit. Further, the policy revealed under the section titled, Narcotic Administration that the nurse will, 4. Sign out the Narcotic from the declining sheet in the Narcotic Book immediately after taking out of the card. N.J.A.C. 8:39-29.77(c)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain dignity during meal services for 1 of 3 residents (Resident #89) observed who required assistance with eating. This deficient practice was evidenced by the following: 1. On 04/04/24 at 12:21 PM, the surveyor observed Resident #89 being fed by a Licensed Practical Nurse (LPN) in the main dining room. The LPN stood over Resident #89 who was seated at a dining table. At 12:28 PM, the LPN walked away from Resident #89 to assist another resident. When the LPN returned to Resident #89, she sat next to the resident while she fed him/her. At 12:36 PM, the LPN stood back up and continued to feed Resident #89 while standing over the resident. During an interview with the surveyor on 04/04/24 at 12:40 PM, the LPN stated that when staff feed residents, the staff should be seated in front of the resident for better etiquette. The LPN further stated that she stood up while feeding Resident #89 because her back hurt. 2. On 04/05/24 at 12:15 PM, the surveyor observed Resident #89 sitting up in bed in his/her room. The resident's lunch tray was on an overbed table in front of the resident. The lunch tray was uncovered and set up for the resident to eat. Resident #89 was holding a stuffed animal and was not eating from the lunch tray. At 12:18 PM, the Registered Nurse/Unit Manager (RN/UM) entered Resident #89's room to assist another resident with his/her lunch. Resident #89 was still sitting up in bed with his/her lunch tray uncovered in front of him/her. At 12:28 PM, another staff member entered Resident #89's room, sat next to the resident, and began feeding him/her. During an interview with the surveyor on 04/05/24 at 12:37 PM, the RN/UM stated that the Certified Nursing Assistants (CNA) pass out the meal trays and know which residents require assistance with feeding from their change of shift report. The RN/UM further stated that the CNAs pass out the feeder trays last and keep the trays covered until they are ready to feed the resident. The RN/UM also stated that staff should be sitting next to the resident while feeding to promote an individualized experience and make it pleasurable for the resident. According to the Admission Record, Resident #89 had diagnoses which included, but were not limited to, dementia and Alzheimer's Disease. Review of the significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/27/24, included the resident had a Brief Interview for Mental Status score of 00, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident was on hospice services. Review of the Care Plan, revised 03/12/24, included Resident #89 was at risk for weight loss due to sporadic food and fluid intake 2nd [secondary] to dementia, with an intervention that, staff will continue to feed & encourage [Resident #89] to complete all food and fluids. During an interview with the surveyor on 04/05/24 at 1:02 PM, the Assistant Director of Nursing (ADON) stated that the CNAs pass out the meal trays, but if the resident was a feeder, the CNA would hold the tray until they were ready to feed the resident. The ADON further stated that when staff feed residents, they should be sitting at eye level to the resident for dignity reasons. During an interview with the surveyor on 04/05/24 at 1:06 PM, the Director of Nursing (DON) stated the CNAs and nurses pass out the meal trays, but will save the feeder trays until last when the staff can feed the resident. The DON further stated that staff should not leave a tray uncovered in front of a resident that staff weren't ready to feed because the food could get cold. The DON also stated that when staff feed residents, it is important for staff not to stand over the resident for the resident's dignity. When informed of the observations made by the surveyor the DON verified that the LPN should have asked another staff member to feed Resident #89 if the LPN could not tolerate sitting, and that staff should not have left Resident #89's meal tray uncovered in front of him/her if the staff were not ready to feed the resident. Review of the facility's Meal Pass policy, dated 10/2023, included, Should the resident require assistance with feeding, the resident will be assisted by a qualified staff member. The policy did not include how staff should be feeding residents. NJAC 8:39-4.1(a)12

Complaint NJ #: 169845 Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to address a.) fall prevention interventions and b.) pressure ulcer interventions. This deficient practice was identified for 2 of 19 residents reviewed for resident-centered care plans (Resident #62 and #397) and was evidenced by the following: 1.) According to the Admission Record, Resident #62 was admitted to the facility with the diagnoses which included but was not limited to spinal stenosis (condition where spinal column narrows and compresses the spinal cord) and abnormality of gait and mobility. The admission Minimum Data Set (MDS) an assessment tool which facilitates resident's care dated 03/02/24, indicated that Resident #62 scored a 7 out of 10 on the Basic Interview for Mental Status (BIMS) which indicated that the resident had moderate impairment in cognitive status. On 04/04/24 at 12:10, the surveyor observed Resident #62 in the main dining room. The resident was unable to be interviewed due to decreased cognitive status. The resident was observed sitting in a geri-chair (reclining chair) in a reclining position at the table. The surveyor observed a chair alarm attached to the back of the chair. The surveyor asked the Licensed Practical Nurse (LPN #1) if the resident could sit in a regular chair for meals and she stated that the resident was in the reclining chair because she was identified as a high risk for falls. The surveyor reviewed Resident #62's electronic medical record which revealed the following information: The admission Progress Note dated 02/24/24 at 01:33 PM (13:33 hours), indicated that Resident #62 was a new admission and scored a 8 on the fall assessment which indicated that the resident was at a moderate risk for falling. The Treatment Administration Record (TAR) dated 02/24/24, reflected a physician's order (PO) for the resident to have a bed alarm and for staff to check every shift for placement and function for safety. The TAR also reflected a PO dated 02/24/24 for Resident #62 to have a chair alarm and for staff to check every shift for placement and function for safety. The Occupational Therapy Discharge Summary dated 02/24/24-04/04/24 indicated that discharge recommendations included: geri-chair (reclining chair) for out of bed positioning to enable safe mobility and for fall monitoring. The surveyor reviewed Resident #62's Care Plan (CP) which did not include documentation regarding fall interventions for the geri-chair, bed alarm or chair alarm. On 04/05/24 at 11:30 AM, the surveyor observed that the resident was not in her room. The surveyor observed a bed alarm attached to the bed. On 04/05/24 at 11:47 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that she had been employed in the facility for 4-5 months. The CNA described the resident as feisty and confused. She stated that the resident required total care with all aspect of activities of daily living (ADLs). She stated that the resident was incontinent and wore protective briefs for vanity and hygiene and that the resident's skin was intact. She stated that the resident was able to feed himself/herself and wore hearing aids. She continued to explain that the resident got up every day to the geri-chair and had bed alarm and chair alarm because he/she was at risk for falls and had the potential to lean forward out of the w/c. On 04/05/24 at 12:10 PM, the surveyor observed Resident #62 sleeping in the geri-chair, reclined at the table in the main dining room. On 04/05/24 at 12:54 PM, the surveyor interviewed the Director of Rehabilitation (DOR) who stated that Resident #62 was discontinued from therapy on 4/4/24. The DOR explained that Resident #62 was receiving PT for strengthening, balance, transfer training and sit to stand modalities. He stated that on admission residents were provided with a wheelchair (w/c) and evaluated to assure appropriateness (size, height, depth, and any other accessories added to the w/c). He stated that nursing would make the decision if the resident was to utilize a geri-chair. He stated that Resident #62 was utilizing a geri-chair for positioning and fall monitoring. On 04/05/24 at 01:18 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that Resident #62 utilized the geri-chair because the resident was agitated at times and was not able to ambulate by himself/herself. She stated that when the resident was up in a regular wheelchair he/she was able to get up on his/her own and had the potential to fall. She stated that the resident was evaluated by therapy and that the geri-chair was recommended. The RN/UM also added that the resident had a physician's order for a bed alarm and a chair alarm. The UM reviewed the CP in the presence of the surveyor and stated that that all fall preventions devices such as the geri-chair, bed alarm and chair alarm should be documented in the CP. The RN/UM confirmed that these devices were not implemented on the resident's CP. On 04/05/24 at 01:10 PM, the surveyor interviewed LPN #2 stated that Resident #62 was alert with confusion, took medication crushed, was a fall risk and utilized a bed alarm and chair alarm. She stated that the resident required total care with all aspects of ADLs and did not receive therapy at this time. She stated that the resident did not have a history of falls. She explained that physical therapy (PT) made the determination if the resident was appropriate for the use of a geri-chair. She stated that Resident #62 moved alot in the geri-chair and would scoots to the front of the chair which then required reminders to sit back in the chair so that he/she did not fall. She stated that when fall interventions were instituted such as a geri-chair, bed alarm and chair alarm the fall interventions should be documented in the care plan and the physicians' orders. On 04/09/24 at 09:31 AM, the surveyor interviewed the DON who stated that when a resident was admitted a fall risk assessment was completed and that the residents were evaluated by PT and occupational therapy (OT). The DON confirmed that fall prevention interventions should be put into the residents Care Plan (CP). She stated that the CP to specify what the residents fall interventions were and what goals the resident had and was also a form of communications between the interdisciplinary team. She continued to state that each Department was responsible to update the CP and this usually took place during the resident's care conference. The facility policy titled, Care-Plans Comprehensive with a revised date of 06/2023, indicated that each resident comprehensive care plan was designed to reflect treatment goals. The CP interventions were designed after careful consideration of the relationship between the resident's problem areas, their causes, resident feedback, and preferences. The policy indicated that CP revisions and assessment of resident was ongoing and CPs were revised as information about th resident and the resident's condition change. 41260 2.) On 04/04/24, the surveyor reviewed Resident #397's closed record: According to the Admission Record, Resident #397 had diagnoses which included, but were not limited to, pressure ulcer of the sacral region stage 4, protein-calorie malnutrition, diabetes mellitus, adult failure to thrive, and dementia. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/05/23, included the resident had a Brief Interview for Mental Status score of 03, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident had one unstageable pressure ulcer that was not present upon admission to the facility. Review of a Progress Note, dated 08/18/23 and written by the wound care consultant (WCC), revealed the resident had an unstageable pressure ulcer to the sacrum. Further review of the progress note included the following preventative measures: The patient continues on an alternating air/low air loss mattress for pressure redistribution. Ensure settings are maintained at an appropriate level based on the patient's needs and body habitus, and the following new recommendations: apply a pressure redistributing cushion to wheelchair when out of bed. Review of a Progress Note, dated 08/25/23 and written by the WCC, included the same preventative measures and recommendations as the 08/18/23 note. Review of a Progress Note, dated 09/14/23 and written by the WCC, included the same preventative measures as the 08/18/23 note, but included the new recommendation of a ROHO cushion (specialized wheelchair cushion) if out of bed. Review of the Order Summary Report, as of 10/20/23, did not include any physician orders for an air mattress or wheelchair cushion. Review of the Care Plan included a focus, dated 08/18/23 with no revision date, that Resident #397 had a sacral pressure ulcer, but the interventions did not include an air mattress or wheelchair cushion. During an interview with the surveyor on 04/10/24 at 10:03 AM, the DOR stated that if a resident needed a ROHO cushion, the nursing department would put in a request to the therapy department who would provide the cushion. When asked about Resident #397, the DOR stated the resident received therapy services in September 2023 and had been given a ROHO cushion from the therapy department, but was unable to provide any related documentation. During an interview with the surveyor on 04/11/24 at 9:15 AM, CNA #2, stated she knows which residents have pressure ulcer preventative devices from the change of shift report. CNA #2 further stated that the nurses were responsible for ensuring the air mattresses and wheelchair cushions were in place and functional. CNA #2 added that the importance of air mattresses and wheelchair cushions were to help heal pressure ulcers. During an interview with the surveyor on 04/11/24 at 9:20 AM, LPN #3 stated that she knows if a resident has an air mattress or wheelchair cushion because they will be included on the resident's care plan. LPN #3 further stated that a physician's order would be obtained for an air mattress and a ROHO cushion as well. LPN #3 added that the Unit Manager updates the resident care plans and that it was important to include pressure ulcer preventative measures on the care plan because, it is part of the resident's care program and if it is not documented anywhere, it wasn't done. During an interview with the surveyor on 04/11/24 at 9:25 AM, RN/UM #2 stated she was unsure where a resident's air mattress and wheelchair cushion would be included in the resident's medical record. RN/UM #2 further stated that each department was responsible for updating the care plans and that it would be important for pressure ulcer preventative measures to be included on the care plan in order to help with the overall healing of the wound and prevent worsening of the wound. During an interview with the surveyor on 04/11/24 at 10:00 AM, the Assistant Director of Nursing (ADON) stated that the nurse would know which residents had an air mattress or ROHO cushion because it would be included in the physician's orders. The ADON further stated that the nurse was responsible for checking the placement and function of the air mattress and wheelchair cushion in order to prevent worsening of the pressure ulcer. When asked about care plans, the ADON stated the nursing department updates the care plans and that she would expect an air mattress and wheelchair cushion be included for a resident with a pressure ulcer to make everyone aware and so that everyone is doing the best practice for the resident to prevent worsening of the wound. During an interview with the surveyor on 04/11/24 at 10:30 AM, the DON stated that staff know if a resident has an air mattress or wheelchair cushion because it would be included on the resident's care plan. The DON further stated that it was important to include these interventions on the care plan to prevent worsening of the wound and to let other staff know what treatment is going on with the resident. Review of the facility's Care-Plans Comprehensive policy, revised 06/2023, included, Each resident's comprehensive care plan is designed to: . Aid in preventing or reducing declines in the resident's functional status and/or functional levels, and, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. NJAC 8:39-11.2(i) NJAC 8:39-27.1(a)

Based on observations, interview, and review of facility documentation it was determined that the facility failed to reconcile a physician order and accurately document on the Medication Administration Record (MAR) for a resident receiving enteral feedings (artificial nutrition given through a tube placed into the stomach). This deficient practice was identified for 1 of 19 resident reviewed for professional standards of nursing practice (Resident #446). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as followed: On 04/03/24 at 11:00 AM, during the initial tour the surveyor observed Resident #446 lying in bed with their spouse at the bedside. At that time, the surveyor observed the resident receiving nutritional supplement administered via a tube feeding pump (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth). The surveyor reviewed the medical record for Resident #446. A review of the Admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included dysphagia (difficulty swallowing), dysarthria (difficulty speaking), and gastrotomy (creation of an artificial external opening into the stomach for nutritional support). A review of the admission Minimum Data Sheet (MDS), an assessment tool, dated 3/25/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 05 out of 15, which indicated the resident had severe cognitive impairment. A further review of the MDS in Section GG: Functional Abilities and Goals, included under eating the resident was coded an 88 (not attempted due to medical conditions or safety concerns). A review of the April 2024 Medication Review Report revealed the following: start date 03/21/24: NPO [nothing by mouth] diet, NPO texture, NPO consistency for dysphagia. start date 03/28/24: Enteral Feed order every day shift for nutrition. Document TV [total volume] infused daily once feeding completed. start date 03/19/24: HS [bedtime] snack at bedtime accept or decline. A review of the March 2024 Medication Administration Record (MAR) reflected the following: On 3/22/24, 3/23/24, 3/24/24, 3/30/24 and 3/31/24 the nurses documented the resident accepted the HS snack. On 3/20/24, 3/21/24, 3/25/24, 3/27/24, 3/28/24 and 3/29/24 the nurses documented the resident declined the HS snack. A review of the April 2024 MAR reflected the following: On 04/01/24, 04/02/24, and 04/06/24 the nurses documented the resident accepted the HS snack. On 04/03/24, 04/04/24, 04/05/24, 04/08/24 and 04/09/24 the nurses documented the resident declined the HS snack. On 04/10/24 at 12:44 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that if a resident was NPO they would not receive an HS snack. The CNA explained NPO indicated the resident was not able to receive anything by mouth. She stated she was only aware of one resident that was a tube feed and received a meal tray, but confirmed it was not Resident #446. On 04/10/24 at 01:24 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) for resident #446. The LPN stated that the resident was NPO and did not receive any meal trays. She stated that since the resident was nothing by mouth, they would not be offered an HS snack. She further stated that the resident should not have an order for an HS snack since they were NPO. At that time, the LPN reviewed the physician orders in the electronic medical record (EMR) and confirmed there was the active physician order for an HS snack. She then acknowledged that the resident should not have that order because the resident was NPO. Upon further review the LPN stated that it was ordered on 3/19/24 and entered in EMR by the evening shift 3pm to 11pm supervisor. She stated that the 7p to 7a nurse was responsible for chart reconciliation. The LPN concluded that the HS snack needed to be discontinued. On 04/10/24 at 01:30 PM, the surveyor interviewed the Director of Nursing (DON) who stated that not all residents who received enteral feeding were NPO. She explained that some residents could receive a meal tray based on their assessment. The DON then stated that if a resident had an order for NPO then they would not receive a tray because NPO was nothing by mouth. She further stated that they should not be offered any snacks or anything to drink unless they were cleared by the physician to have it. At that time, the DON reviewed the EMR which indicated the resident received enteral feeds and was NPO. She then confirmed the resident had an order for HS snack which was discontinued on today 04/10/24. She stated that the night shift 7p to 7a nurses completed the reconciliation of orders. The DON stated the facility input automatic batch orders on admission and HS snacks was one of them. She then reviewed the MAR in the presence of the surveyor and confirmed the nurses check marked that the HS snack was accepted three (3) times for April 2024. The DON acknowledged that if it the resident was NPO then they should not have had an order or been offered an HS snack. A further review of the April 2024 MAR reflected the HS snack was discontinued on 04/10/24 after surveyor inquiry. On 04/11/24 at 11:01 AM, the DON stated that the resident never received an HS snack and that the nurses just documented something to mark if off and acknowledged it was documented incorrectly. The DON confirmed the order should have been discontinued and reconciled prior to surveyor inquiry. A review of the facility's Admission/Readmission Order Reconciliation policy, updated 08/2023, included, 1. Review the hospital records, if a physician is not present, place a call to an on-call physician for Medication Reconciliation and verification of orders with diagnosis for every medication. A review of the facility's NPO diet policy, updated 01/2024, included, 1. Nothing by mouth (NPO) status means that a resident is not allowed to consume any foods or fluids orally. A. unless otherwise indicated by the residents' healthcare provider. 2. All aspects of the residents NPO status will be documented properly in the resident's EMAR [electronic medication administration record] chart. A review of the facility's HS Snack policy, dated reviewed 10/2023, included, 1. Due to there being more than 14 hours between meals, there is an evening snack being offered to residents who qualify. N.J.A.C. 8:39-27.1 (a)

Complaint NJ #: 169845 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control practices and professional standards during a pressure ulcer treatment for 1 of 2 residents (Resident #447) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 04/05/24 at 1:23 PM, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound care treatment on Resident #447. The LPN performed hand hygiene using alcohol-based hand rub (ABHR) and then donned gloves. She wiped down the overbed table with a disinfectant wipe, washed her hands for 40 seconds, and gathered the treatment supplies onto the overbed table, which included a tube of santyl ointment (removes damaged tissue). The LPN donned gloves, repositioned the resident, removed the old wound dressing, and removed her gloves. The LPN then donned new gloves without performing hand hygiene, cleansed the wound with normal saline solution (NSS), and removed her gloves. The LPN donned new gloves again without performing hand hygiene, soaked a gauze with NSS, dispensed the santyl ointment from the tube onto the NSS soaked gauze, and applied the gauze to the wound. The LPN then applied a border gauze dressing to cover the wound without first writing the date and time on the dressing before the application. The LPN removed her gloves, did not perform hand hygiene, grabbed a marker from her pocket, donned new gloves, and wrote the date and time on the dressing over the resident's wound. At that time, the resident groaned in pain and the LPN asked the resident if he/she wanted any pain medication. The LPN then repositioned the resident in bed, disposed of all of the treatment supplies, except for the tube of santyl, removed her gloves, and washed her hands for 20 seconds. The LPN donned gloves and took the tube of santyl ointment from the overbed table and put it back into the treatment cart. Afterwards, the LPN wiped down the overbed table with a disinfectant wipe. According to the Admission Record, Resident #447 had diagnoses which included, but were not limited to, diabetes, sepsis (severe body response to infection), and cellulitis (skin infection). Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/27/24, included the resident had a Brief Interview for Mental Status score of 15, which indicated the resident's cognition was intact. Further review of the MDS included the resident had a Stage 4 pressure ulcer present on admission and two Unstageable pressure ulcers present on admission. Review of the Medication Review Report, dated 04/05/24, included a physician's order to Cleanse wound with NSS, apply Santyl, cover with moistened gauze, cover with border gauze, every day shift for wound care, with a start date of 03/25/24. Review of the Care Plan, revised 03/22/24, included Resident #447 had an alteration in skin related to decreased mobility with an intervention to administer treatments for skin impairment as ordered. During an interview with the surveyor on 04/05/24 at 1:50 PM, the Infection Preventionist (IP)/Assistant Director of Nursing (ADON) stated that staff should be performing hand hygiene between glove use to prevent the spread of infection. The IP/ADON further stated that the nurse should not bring multidose containers, such as a tube of ointment, into a resident's room because it isn't sanitary when returned to the treatment cart. The IP/ADON explained that the nurse should dispense the amount needed for the treatment into a medicine cup to bring into the resident's room. The IP/ADON further stated that the nurse should label the wound dressing prior to applying it to the wound to prevent pushing into the wound with the pen or marker. During an interview with the surveyor on 04/05/24 at 1:58 PM, the Director of Nursing (DON) stated that the nurse should be performing hand hygiene between removing the old, dirty wound dressing and putting on the new, clean wound dressing to prevent introducing anything dirty to the wound. The DON further stated that the nurse should dispense a multidose ointment into a medicine cup to bring into the resident's room to prevent the spread of infection. The DON also stated that the nurse should label the wound dressing prior to putting it on the wound for dignity reasons. Review of the Wound Care policy, dated 12/2023, included, Perform hand hygiene, put gloves on, and remove old dressing . Wash hands thoroughly. Put a clean pair of gloves on. Follow treatment as ordered. Ensure new wound treatment has a current date and initialed. Review of the facility's Handwashing/Hand Hygiene policy, undated, included, Appropriate twenty (20) seconds hand washing with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions: . After removing gloves, and, The use of gloves does not replace hand washing. NJAC 8:39-27.1(a)

Based on interview, review of medical records and review of other pertinent facility documentation it was determined that the facility failed to a.) follow the facility policy that was in place for resident identification and b.) to coduct a through/complete investigation for 1 of 4 resident reviewed for incidents and accidents (Resident #62). This deficient practice was evidenced by the following: According to the Admission Record (AR), Resident #61 was admitted to the facility with the diagnoses which included but was not limited to hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS) an assessment tool which facilitates resident's care dated 02/24/24, indicated that Resident #61 had severe cognitive deficits and required partial to moderate assistance with activities of daily living. The MDS also reflected that the resident required help with functional cognition such as planning regular task such as shopping, remembering to take medications prior to current illness. According to the AR, Resident #62 was admitted to the facility with the diagnoses which included but was not limited to spinal stenosis (condition where spinal column narrows and compresses the spinal cord) and abnormality of gait and mobility. The admission MDS dated [DATE], indicated that Resident #62 scored a 7 out of 15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident had moderate impairment in cognitive status. The MDS also reflected that the resident required help with functional cognition such as planning regular task such as shopping, remembering to take medications prior to current illness. On 04/09/24 at 12:00 AM, the surveyor reviewed an Incident and Accident Report (IAR) dated 02/28/24 at 07:15 am, which indicated that Resident #62 was involved in a misidentification and transport error. The IAR indicated that Resident #62 was taken by medical transport to a medical doctor's office in error. According to the facility investigation dated 02/28/24, Resident #62 was misidentified and taken by transport to the medical doctor's office in error and was returned to the facility and assessed for injury. The investigation indicated that no injury had occurred and that family and physician were notified. There was no documentation on the investigative report which indicated how this event occurred or how this event could have happened. There was no documentation regarding how the Registered Nurse (RN) assigned to the resident on 02/28/24 from 7:00 PM- 7:00 AM, misidentified the resident and sent the resident by mistake out on transport to a medical doctor's office. The causes of this incident were not identified on the investigative report. The investigative report did not contain a statement from the Licensed Practical Nurse (LPN #1) that identified that the resident was sent to a medical doctors appointment by mistake. On 04/10/24 at 09:03 AM, the surveyor interviewed the Director of Nursing (DON) regarding misidentification of Resident #62. The DON stated that Registered Nurse (RN) assigned to Resident #62 on 02/28/24 at 7:00 PM to 7:00 AM, thought that Resident #62 had an appointment offsite to a medical doctor and sent Resident #62 out to appointment by ambulance transport company. The surveyor asked the DON why the RN sent Resident #62 and how the RN could have misidentified the resident. The DON stated that she didn't know why and indicated that the nurse assigned to the resident thought that Resident #62 had the appointment. The DON stated that the transport paperwork indicated that Resident #61 (Resident #62's roommate) was supposed to go out for the appointment. The DON stated she did not ask the RN during her investigation why or how she misidentified the resident. She stated that she thought it was because the resident did not have a name band. On 04/10/24 at 09:59 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who explained the process for scheduling and transporting resident to an outside appointment. He explained that the Administrative Assistant (AA) scheduled residents outside medical doctors' appointments. He stated that the AA would notify the nurse assigned to the resident by way of a paper form or by verbal communication. He stated that the AA then scheduled the transport and confirmed the appointment with the provider. He then explained that when residents were being transported by ambulance to outside doctors appoints that the nurse should identify the resident with the name band or picture prior to being transported. He then continued to explain that cognitively impaired residents were sent with an escort because the facility wanted to ensure the residents were safe. The LNHA confirmed that Resident #62 was cognitively impaired and was sent out of the facility without an escort. The LNHA could not speak to why LPN #1 who identified Resident #62 was sent to the medical appointment by mistake was not interviewed or did not write a statement during the investigation. The LNHA confirmed that Resident #62 was sent out of the facility by mistake on 02/28/24 and he explained that after the 7:00 PM to 7:00 AM RN sent the wrong resident (Resident #62), the 7:00 AM to 7:00 PM Licensed Practical Nurse (LPN) came in and that this LPN who was very familiar with Resident #62 and Resident #61 questioned why Resident #61, who was supposed to have a neurology appointment was still in the facility and then identified that the wrong resident, Resident #62 was sent in error. The LNHA stated that transport was then notified and were asked to return the resident to the facility. When Resident #62 returned to the facility, the resident was assessed, and no injury was noted. The LNHA stated that Resident #62's family and physician were notified. The LNHA could not speak to why the LPN who identified that Resident #62 was sent to the medical appointment by mistake, was not interviewed or did not write a statement during the investigation. The LNHA then stated that he could get the statement from the LPN at this time. The LNHA did not have a response as to why the RN who sent Resident #62 instead of Resident #61, misidentified Resident #62. On 04/10/24 at 10:34 AM, the surveyor interviewed LPN #1 who worked 7:00 AM-7:00 PM on 2/28/24. The LPN stated that she came in around 7:30 AM on 02/28/24 and made rounds. She stated that she observed that both Resident #61 and Resident #62 were not in their rooms. LPN #1 then identified that the Resident #62 was sent by mistake to Resident #61's neurology appointment. She explained that at same time she identified that Resident #62 was sent to the appointment by mistake, the daughter of Resident #61 called that facility, because she was waiting at the doctor's office for resident #61, to inform the facility that they sent the wrong resident. The RP for Resident #61 notified the facility that the resident they transported to the doctor's appointment was not Resident #61. LPN #1 stated that she was not asked to write a statement regarding these events however she completed the incident report and wrote a progress note. She also stated that she assessed the resident when she returned to the facility and that the resident was fine and free from injury. She stated that the process for identification of residents was the name band and picture on the face sheet. She stated that there was also a picture on the face sheet that was included in the resident's transport paperwork. She stated that she was not aware of how the RN sent the wrong resident out of the facility. On 04/10/24 at 11:15 AM, the surveyor interviewed the Administrative Assistant (AA) who scheduled appointments for residents. She stated that she was given the orders by the charge nurse. She stated that she prepared all paper such as the resident face sheets, resident insurance information, resident consult request, resident labs, resident medication list, and resident progress notes. She stated that she then notified family or responsible party (RP) when appointment was scheduled. She stated that if the resident was cognitively impaired, the resident absolutely had to be escorted. She then stated that if no family could accompany the resident, then a CNA was required to accompany the resident. She stated that cognitively impaired resident could not go out on transport by themselves. She explained that the facility could not send someone somewhere where they could not verbally consent to treatment or answer questions regarding their medical condition. She stated that she had been scheduling resident appointment for [AGE] years and that she always made arrangements to have a cognitively impaired resident escorted to an outside physician appointment. She then stated that the face sheet that was included in the transport paperwork contained a resident picture, and that all paperwork had the residents name attached. On 04/10/24 at 11:37 AM, the surveyor interviewed Resident #62 RP who stated that she was informed immediately that her mother/father was sent by mistake to an appointment. She stated that Resident #62 was stable and suffered no untoward effects after returning to the facility. On 04/10/24 at 11:40 AM, the surveyor attempted to interview telephone interview the 7:00 PM-7:00 AM RN who misidentified resident #62 and sent the resident to Resident #61's neurology appointment. There was no answer. Left message to return the surveyor's call. On 04/11/24 at 10:22 AM, the surveyor interviewed LPN #2 who explained the facility process for identification of residents. She stated that identification was done by picture, name bracelets and asking the resident what their name was. She stated that when sending residents out of the facility to appointments, that the nurse should verify the time of the appointment and how the resident was being transported. She stated that the nurse should assure that the transport company received the transport paperwork. She stated that if the resident being transport was not coherent enough, an escort was assigned to go with them. She stated that the resident scheduling list was posted at the nursing station. She stated that it was the nurse's responsibility to check this list when they come in for their shift to assure that residents go to their appointments. She stated that the nurse would inform the assigned CNA during report who had an appointment and what time the resident was going so that the CNA could get the resident ready. She stated that if you are not familiar with the identification of a resident the nurse should check name on the resident's door, name bracelet, picture, and ask the staff and CNA to identify the resident. On 04/11/24 at 10:36 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) for the Lower [NAME] Unit. The RN/UM stated that the identification of residents should be done by resident name tag, resident picture and asking them their name. She stated that cognitive impaired residents were sent with an escort and AA would usually document on the appointment list posted at the nurse's station, the name of the individual escorting the resident. She stated that if the residents RP was meeting the resident at the MDs office it would also be documented on the appointment list. She stated that it would be important to assure an escort went out with the resident because the cognitively impaired resident could not advocate for themselves. She explained that incidents were documented in the progress notes. She stated that the DON was responsible to complete the investigation and document any interventions that were implemented. If there is an accident or incident with a resident, the assigned nurse fills out the incident report and gets statement from staff or anyone involved. The facility policy titled, Transportation Policy dated 01/2024 indicated that upon arrival the transportation company and the nurse will identify the resident going out along with the transportation staff. The undated facility policy titled, Patient Identification indicated that acceptable means to identify residents may include the following but were not limited to: -Checking the individuals name by asking if the able to verify. -Staff verification of the resident's name. -Checking the medical record number on the face sheet. -Verifying and checking date of birth, photographs which are located on the face sheet. -Checking the ID bracelet to confirm resident's identification. The facility policy dated 03/2023 titled, Incident/Accident policy and Procedure indicated that it was the policy of the facility to provide a system whereby resident incidents and accidents were reported their causes identified when possible, timely interventions were established to reduce the probability of repeated incidents. The policy alos indicated that all employees assigned to the resident involved in the incident and accident would fill out the Employee Statement Form. NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag was stored and maintained in a manner to prevent urinary tract infections for 1 of 3 residents (Resident #40) reviewed for urinary catheters. This deficient practice was evidenced by the following: On 04/04/24 at 11:53 AM, the surveyor observed Resident #40 lying in bed and the resident had a urinary catheter. The privacy cover was secured to the resident's bed, but the drainage bag was on the floor, not in the privacy cover. The drainage bag was empty and had the date 04/03/24 written on it. During an interview with the surveyor on 04/05/24 at 9:55 AM, the Certified Nursing Assistant (CNA) stated that the CNAs were responsible for emptying the urinary catheter drainage bags. The CNA further stated that the drainage bag should not touch the floor. At that time, the surveyor accompanied the CNA to Resident #40's room so the CNA could demonstrate how to empty the drainage bag. The CNA donned gloves and a gown, removed the drainage bag from the privacy cover hanging on the resident's bed, verified the drainage bag was dated 04/03/24, emptied the bag into a urinal, emptied the urinal into the toilet, and discarded her gloves and gown. The CNA then turned on the sink in the resident's bathroom to wash her hands, dispensed soap into her hands, and then lathered her hands with soap under the stream of water. During a follow-up interview with the surveyor on 04/05/24 at 10:04 AM, the CNA stated that the process for hand washing included lathering hands with soap outside of the stream of water for 20 seconds. The CNA further stated that the importance of lathering hands outside the stream of water was to remove the germs from hands because otherwise the water will wash the soap off. According to the Admission Record, Resident #40 had diagnoses which included, but were not limited to, urinary tract infection, sepsis (severe body response to infection), cystitis (bladder infection), retention of urine, and hematuria (blood in the urine). Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/02/24, included the resident had a Brief Interview for Mental Status score of 14, which indicated the resident's cognition was intact. Further review of the MDS included the resident had an indwelling catheter. Review of the Care Plan, revised 11/02/23, included Resident #40 had an indwelling urinary catheter related to urinary retention but did not include interventions on how to maintain the urinary catheter to prevent urinary tract infections. During an interview with the surveyor on 04/05/24 at 10:22 AM, the Licensed Practical Nurse (LPN) stated that the CNAs were responsible for emptying the catheter drainage bags and that the drainage bag should be secured below the resident, but not touching the floor for infection control reasons. The LPN explained that if the drainage bag was on the floor, the CNA should notify the nurse to change the bag. The LPN further stated that hands should be washed by lathering hands with soap outside the stream of water in order to stop the spread of germs. During an interview with the surveyor on 04/05/24 at 10:31 AM, the Infection Preventionist (IP)/Assistant Director of Nursing (ADON) stated that CNAs were responsible for emptying the catheter drainage bags and that drainage bags should be kept off the floor because the floor is a source of germs and not sanitary. The IP/ADON explained that if the drainage bag was on the floor, the nurse should change out the bag. The IP/ADON further stated that the process for hand washing included lathering hands with soap outside of the stream of water because otherwise you would rinse off the soap that you need to clean the skin. During an interview with the surveyor on 04/05/24 at 10:37 AM, the Director of Nursing (DON), stated the CNAs were responsible for emptying the catheter drainage bags and that the drainage bag should be kept off the floor for infection prevention reasons. The DON explained that if the drainage bag was on the floor, the staff should notify the nurse to change the bag. The DON further stated that hands should be lathered with soap outside the stream of water during hand washing otherwise the soap will wash away and you will only be rinsing with water. Review of the facility's Insertion and Removal of Indwelling Catheter policy, undated, included, Secure urinary drainage bag below the level of the bladder and KEEP OFF THE FLOOR AT ALL TIMES. Review of the facility's Care and Maintenance of Foley Drainage System policy, dated 02/2024, included, All foley drainage bags are to be kept in privacy bags when at the beside or when a resident is in a wheelchair. Review of the facility's Handwashing/Hand Hygiene policy, undated, included, Appropriate twenty (20) seconds hand washing with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions: . After removing gloves. The policy further included, Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for twenty (20) seconds under a moderate stream of running water, at a comfortable temperature. Review of the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, guidelines, dated 01/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. N.J.A.C. 8:39-23.2(a)

Complaint #: NJ169880 and 170054 Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to accurately document in the medical records. This deficient practice was identified for 1 of 22 residents (Resident #398) medical records reviewed and was evidenced by the following: The surveyor reviewed the medical record for Resident #398. A review of the Admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included muscle weakness, difficulty in walking, and cerebral infraction (stroke). A review of the care plan date initiated 11/14/23, reflected a focus of at risk for falls r/t [related to] deconditioning recent hospitalization . 12/2/23 observed on the bathroom floor near wheelchair. Interventions dated 12/2/23, included neurological (neuro) checks post fall, monitor for pain, and Xray to thoracic spine (upper and middle part of back) r/t bruising that evolved after the fall (negative). A review of the Incident/Accident Report revealed the resident had an unwitnessed fall on 12/2/23 at 5:55 PM and was found sitting on the floor in the bathroom, next to their wheelchair. It further indicated the POA was notified at 6:17 PM. A review of the Progress Notes (PN) from December 2023, revealed there was no progress note in the electronic medical record (EMR) on 12/2/23 during the 7am to 7pm shift regarding the fall until 12/3/23 at 01:27 (1:27 AM), which indicated s/p [status post] fall day, no injury noted and neuro check in progress. Upon further review, the PN did not indicate the resident's representative was notified until 12/4/23 at 00:22 (12:22 AM) which reflected, during PM [night] care staff observed a bruise on the resident's back. The POA [power of attorney] and the physician was notified. On 04/10/24 at 12:55 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated Resident #398 was very quiet and was able to stand and pivot but transferred with supervision. The LPN stated that the resident had a history of falls but could only recall one fall. She explained if the resident had a fall, then staff would assess the resident and then document it in the EMR, notify the physician and the family. She further explained that they would document in the EMR as well as complete an incident report. The LPN stated that it was important to also document the fall in the EMR, so everyone was aware that the resident had a fall. She stated that they wrote PN for the next three (3) days and assessed the resident to ensure no bruises or changes occurred with the resident. The LPN stated that the family was notified of the falls because they need to know what happened to their loved ones. She further stated that the resident's representative would be notified right after the incident occurred. The LPN stated that if there was no answer then they would leave a message for the family representative to call back and if it was more than an hour with no call back then they would attempt to call again. On 04/10/24 at 01:43 PM, the surveyor interviewed the Director of Nursing (DON) who stated that there should be a PN included with the incident report. She stated that if you don't document and the paperwork was lost no one would know what was done. She further stated that the PN showed others what was done for that resident. The DON acknowledged the nurses should have written a progress note on 12/2/23 regarding the fall in the EMR. She further acknowledged the nurses should have documented in the PN that family was notified on 12/2/23 in the EMR. The DON emphasized it should be automatic because staff should notify the resident's representative after the resident was assessed. On 04/12/24 at 09:04 AM, in the presence of the survey team both the Licensed Nursing Home Administrator (LNHA) and the DON acknowledged there should have been a progress note associated with the incident report in the EMR. A review of the facility's Incident/Accident Policy and Procedure dated reviewed 03/2023, included, The nurse also informs the responsible party immediately of any injury that may require residents to be transferred from this facility. A review of the facility's Notification of Change policy updated 01/2024, included, notify the resident's legal representative or an interested family member of the following changes. 1. An accident involving the resident which results in injury and has the potential for requiring physician intervention. A review of the facility's Nursing Documentation policy date reviewed 1/2024, included, 1. Gather information and prepare to chart, it is your responsibility as the professional or long term care staff member to document what you found, what you did or did not do for the resident. 5. Proper nursing documentation provides evidence that the nurse has acted as required or ordered. 10. When notifying MD [medical doctor] or family, include name of who you spoke to and the time. 13. Document all events including falls . in [EMR]; 14. Document your assessment post event includes interactions and any resulting actions taken to care for the resident. NJAC 8:39-35.2 (d)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the Nursing Home Resident Care Staffing Report daily. This deficient practice was evidenced by the following: On 04/05/24 at 12:52 PM, the surveyor observed the staffing report posted at the front desk dated 04/04/24 day shift. At that time, a review of the staffing report revealed 04/04/24 evening shift, 04/04/24 night shift, and 04/05/24 day shift was not posted. On 04/10/24 at 10:10 AM, the surveyor observed the staffing report posted at the front desk dated 04/09/24 night shift. At that time, a review of the staffing report revealed 04/10/24 day shift was not posted. On 04/11/24 at 10:40 AM, the surveyor interviewed the Staffing Coordinator (SC) who stated that she was responsible for posting the daily staffing report. She explained she edited it every day and for the weekend she printed them out to be posted. The SC stated that the staffing report was kept at a table across from the front receptionist desk. She further stated that every morning she came in and ensured the posting was updated daily because it included the census, the number of nurses and the number of aides per shift. The SC concluded the staffing report should be updated and posted daily. On 04/11/24 at 12:46 PM, the Licensed Nursing Home Administrator (LNHA) stated in the presence of the Director of Nursing (DON) and survey team that staffing was post in front of the receptionist desk by the state survey book and that it was updated daily. The LNHA stated that the staffing report reflected all three shifts, and that the SC was responsible for updating it. He further stated if the SC did not then the nursing supervisors would also update it. The LNHA stated that the staffing report included, the census and the actual ratio of nursing and aides during that day. A review of the facility's undated Posting of Nursing Ratios policy, included, 2. The proper rations will be updated daily for each shift. NJAC 8:39-41.2

Complaint #: NJ#169185 Based on interview, and record review on 11/21/23 and 11/22/23, it was determined that the facility failed to ensure that discontinued medications for Resident #1 were removed from the active inventory. The failure resulted in the Licensed Practical Nurse (LPN) administering Resident #1's medication to Resident #2. This deficient practice was identified for Resident #1 and Resident #2, 2 of 4 residents reviewed and was evidenced by the following: According to the Admission Record, Resident #1 was admitted to the facility on [DATE] with medical diagnoses that included but were not limited to: acute osteomyelitis (an inflammation or swelling of bone tissue caused by an infection), of the left ankle and foot, open wound of the left foot, and local infection of the skin. Review of Resident #1's Order Summary Report (OSR), for active orders as of 10/1/23, revealed a physician's order (PO), dated 9/18/23, for Ertapenem Sodium Injection Solution Reconstituted (Ertapenem solution) (an antibiotic medication) 1 GM [gram] and to administer 1 GM intravenously (IV) (directly into a vein using a needle or tube) one time a day for osteomyelitis until 10/22/23. Review of Resident #1's October 2023 Medication Administration Record (MAR) revealed the aforementioned 9/18/23 PO for Ertapenem solution and to administer 1 GM, one time a day, with the administration time of 9:00 AM. The MAR revealed that Resident #1 received the medication from 10/1/23 until 10/22/23. According to the Admission Record, Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included but were not limited to: acute osteomyelitis, left ankle and foot, and bacteremia (the presence of bacteria in the bloodstream). Review of Resident #2's OSR, for active orders as of 11/2/23, revealed a PO, dated 11/3/23, for Ertapenem Sodium Injection Solution Reconstituted (Ertapenem solution) 1 GM IV one time a day for L (left) foot infection until 11/28/23. Review of Resident #2's November 2023 MAR revealed the aforementioned 11/3/23 PO for Ertapenem solution 1 GM one time a day with the administration time of 9:00 AM. The MAR revealed that Resident #2 received the medication from 11/3/23 until 11/16/23. Review of the facility's 11/15/23 Complaint Grievance Report, completed by the Social Worker (SW), indicated the facility verified with the family that the correct medication was given with the wrong patient's name on it. Under the Documentation of Investigation section, completed by the LNHA, indicated Correct medication, dose and time, however wrong patient name on the vial. Review of the 11/15/23 Disciplinary Report Form, completed by the Assistant Director of Nursing (ADON), revealed the day shift agency LPN was identified and that the employee did not verify and borrowed medication. Review of the Investigation of Incident/Accident Statement revealed the LPN's statement that I was assigned to Resident #2 on 11/14/2023. I provide IV medication as I was ordered by the medical doctor (MD). I did not realize, by mistake, I took another resident's medication. Medication was the same strength as ordered by the physician but the incorrect name. Resident #2 was stable throughout the shift. Review of a meeting summary completed on 11/15/23 at 3:30 PM by the Licensed Nursing Home Administrator (LNHA), indicated the LNHA, Unit Manager (UM) and SW met with Resident #2's spouse and daughter to discuss questions about Resident #2's care. The daughter mentioned in the meeting that she noticed the correct medication was given but it had someone else's name on the medication. During an interview with the surveyor on 11/21/23 at 12:10 PM, the LNHA stated Resident #2's spouse and daughter reported to him on 11/15/23, they noticed the wrong name on Resident #2's IV medication. The LNHA further stated he identified the LPN assigned to the resident and an investigation was initiated by the facility. The LNHA stated he obtained a verbal statement from the LPN, which indicated she substituted the medication for Resident #2. During an interview with the surveyor on 11/21/23 at 1:58 PM, the Director of Nursing (DON) stated Resident #2 had medication available on the unit, so she was not sure why the LPN used Resident #1's medication. The DON also stated Resident #1 was on the IV Ertapenem solution in October and that it had been discontinued on 10/22/23. During an interview with the surveyor on 11/21/23 at 2:52 PM, the SW stated that on 11/15/23 she attended a meeting with the LNHA, ADON, UM and Resident #2's spouse and daughter. Resident #2's spouse brought a concern to the SW about Resident #2's IV bag, which contained the same medication he was receiving, but had another resident's name on the bag. The SW stated the Unit Manager (UM) would address the issue and investigate further. During a follow-up interview with the surveyor on 11/22/23 at 11:58 AM, the DON stated Resident #1's IV Ertapenem solution was discontinued on 10/22/23. The DON added that once a medication is completed or ended, the nurses should gather all medications, place them in a secured stapled bag, and have the medication picked up the next day. The DON further stated, After a resident is discontinued or finished with a medication, the medication should be discarded. Review of the facility's Medication Storage policy, with a reviewed date of 03/2023, revealed under the Policy section that it is the policy and procedure of this facility to store medications in a safe and proper manner, following all manufacturers recommendations. The policy further revealed under the Procedure section that 3. No discontinued, outdated, or deteriorated medications are available for use in this facility. All such medications are destroyed. NJAC 8:39-29.4(g)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to implement personal protective equipment (PPE) according to the New Jersey Department of Health (NJ DOH) and Centers for Disease Control and Prevention (CDC) guidelines to minimize the potential spread of infection to residents on 3 of 3 units (Upper Willow, Lower Willow, and Redwood Terrace), b) ensure that staff wore proper PPE when caring for newly admitted residents who were under observation for sign/symptoms of COVID-19, and c) minimize the potential spread of infection during wound treatment for 1 of 1 nurses observed during wound treatment observation on 1 of 3 units (Redwood Terrace). This deficient practice was evidenced by the following: 1. On 02/02/22 at 11:50 AM, Surveyor #1 observed Certified Nursing Assistant (CNA) #4 making Resident #332's bed. Resident #332 was seated in a wheelchair next to the bed and the CNA handed the resident part of the bed sheet to assist in making the bed. CNA #4's PPE consisted of an N95 mask with a surgical mask over it. The CNA was not wearing eye protection. During an interview with Surveyor #1 on 02/03/22 at 10:28 AM, CNA #4 stated the required PPE on her assignment was an N95 mask with the option to wear a surgical mask over it and gloves during resident contact. The CNA further stated it was important to wear the correct PPE for infection control purposes. On 02/03/22 at 10:50 AM, Surveyor #1 observed CNA #5 enter Resident #26's room and ask the resident if he/she needed assistance going to the bathroom. The CNA and resident then entered the resident's bathroom together. CNA #5's PPE consisted of an N95 mask. The CNA was not wearing eye protection. During an interview with Surveyor #1 on 02/03/22 at 10:54 AM, CNA #5 stated the required PPE on her assignment was an N95 mask, eye protection, and gloves during resident contact. The CNA then stated that she had goggles but left them at the nurses' station when she answered Resident #24's call light to assist with toileting. The CNA further stated that it was important to wear the correct PPE because of the virus and other infectious things. On 02/03/22 at 10:59 AM, Surveyor #1 observed CNA #6 open the door to Resident #24's room and was bagging up trash and soiled linen. The CNA then assisted the resident with putting on his/her shoe. CNA #6's PPE consisted of an N95 mask with a surgical mask over it and gloves. The CNA was not wearing eye protection. During an interview with Surveyor #1 on 02/03/22 at 11:02 AM, CNA #6 stated the required PPE for her assignment was an N95 mask and gloves during resident contact. The CNA further stated that it was important to wear the correct PPE to prevent contact with germs. On 02/03/22 at 12:15 PM, Surveyor #2 observed CNA #1 was wearing an N95 mask with a surgical mask over it. The CNA was not wearing eye protection. During an interview with the surveyor at this time, CNA #1 stated she wears an N95 mask with a surgical mask over it. She stated it is important to do so to avoid the spread of germs, during contact with residents. On 02/03/22 at 12:16 PM, Surveyor #3 observed the Registered Nurse/Unit Manager (RN/UM) assisting Resident #236 with the lunch meal near the nursing station. Surveyor #2 further observed that the RN/UM's PPE consisted of an N95 mask covered by a surgical mask. The RN/UM did not have on eye protection. On 02/03/22 at 12:18 PM, Surveyor #4 observed the Licensed Practical Nurse/Unit Manager (LPN/UM) sitting next to Resident #12 while feeding the resident in the Lower [NAME] Unit dining room. The LPN/UM was wearing an N95 mask with no eye protection. On 02/03/22 at 12:22 PM, Surveyor #2 observed CNA #2 wearing an N95 mask and eyeglasses, but no eye protection. The CNA was feeding Resident #64 during this time. During an interview with the surveyor at this time, CNA #2 stated she wears an N95 mask. Sometimes they are provided with gowns and PPE, when it is necessary for COVID-19 protection. On 02/03/22 at 12:22 PM, Surveyor #4 observed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) sitting next to Resident # 13 while feeding the resident in the Lower Willow Unit dining room. The ADON/IP was wearing a N95 mask with no eye protection During an interview with Surveyor #4 on 02/03/22 at 12:46 PM, the LPN/UM stated the required PPE for the Lower Willow Unit was an N95 mask and to wear gloves and a face shield when performing direct resident care. During an interview with the survey team on 02/03/22 at 1:13 PM, the ADON/IP stated the required PPE throughout the facility was an N95 mask. The ADON/IP then stated the COVID-19 Activity Level Index ([NAME]) score was high for the southwest region where the facility is located. When asked what the current transmission rate for Camden County (where the facility is located) was, the ADON/IP stated she was unsure how to obtain that information. The ADON/IP further stated that it was important for staff to wear the correct PPE because they give direct care to the residents and the correct PPE prevents exposure to the residents and staff. Review of the current [NAME] report for the southwest region of NJ, provided by the ADON/IP on 02/03/22 at 1:46 PM, indicated the activity level was high. Review of the current CDC COVID Data Tracker for Camden County, provided by the ADON/IP on 02/03/22 at 2:09 PM, indicated the transmission rate was high. Review of the NJ DOH Executive Directive 20-026 included, Facilities shall implement universal eye protection, in addition to source control and other infection prevention and control measures, for all staff and for compassionate care or essential caregiver visitors unable to maintain social distancing when the NJDOH [NAME] Level is Very High/High or Moderate. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic guidelines, revised 02/02/22, revealed the Implement Universal Use of Personal Protective Equipment section was last updated on 02/10/21 and included, If [CONDITION(S)]-coV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP [healthcare professionals] working in facilities located in counties with substantial or high transmission should also use PPE as described below: . Eye protection (i.e. goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. 2. On 02/02/22 at 2:59 PM, Surveyor #3 observed a staff member in a resident's room while on the persons under investigation for COVID-19 (PUI) unit. The surveyor observed a yellow sticker tab next to the room number (yellow tab), a bin containing PPE next to the doorway and signage posted indicating the room was a PUI room. Surveyor #3 further observed the staff member sitting next to the resident's bed within six feet of the resident. The staff member's PPE consisted of an N95 mask and gown. Surveyor #3 further observed that the staff member did not don on eye protection or gloves prior to entering the PUI room. Upon exiting the PUI room at 3:16 PM, Surveyor #3 conducted an interview with the staff member, who identified herself as the Director of Social Services (DSS). The DSS stated that the yellow tab indicated the residents were recently admitted and considered PUI. The DDS stated the required PPE to enter a PUI room was a gown, an N95 mask, and goggles over glasses. When asked why she did not don on eye protection prior to entering a PUI room, the DDS acknowledge that she did not have on goggles over her glasses and responded, that she just happened to step in the resident's room quickly. During an interview with Surveyor #3 on 02/03/22 at 12:29 PM, the RN/UM stated they followed a color code system to determine the required PPE needed to enter a resident's room. The RN/UM stated that green-tabbed rooms required standard precautions and N95 masks; yellow- and red-tabbed rooms required full PPE which included goggles, N95 masks, gowns and gloves. The RN/UM further stated it was important to wear the proper PPE for infection control and to protect from getting COVID-19. During an interview with Surveyor #3 on 02/04/22 at 10:55 AM, the ADON/IP stated she expected staff to don the appropriate PPE when entering PUI rooms. The ADON/IP further stated the required PPE for PUI room was a gown, gloves, an N95 mask, goggles, or face shield. On 02/07/22 at 12:13 PM, Surveyor #3 observed a staff member in a resident's room on the PUI unit. Surveyor #3 observed a yellow tab next to the room number, a bin containing PPE next to the doorway and signage posted indicating the room was a PUI room. The staff member was within six feet of the residents and was observed touching the curtains while in the resident's room. The staff member's PPE consisted of an N95 mask and goggles. The staff did not have on a gown or gloves while assisting the residents in the PUI room. Upon exiting the PUI room at 12:16 PM, Surveyor #3 conducted an interview with the staff member, who identified herself as a CNA (CNA #7). CNA #7 stated the required PPE for PUI rooms was an N95 mask, gown, gloves, and face shield or goggles. CNA #7 further stated it was important to wear proper PPE in PUI rooms for contact precautions. A review of the facility's undated Prevention and Control of COVID-19 policy, revealed that infection prevention and control recommendations for PUI included to adhere to standard, contact, droplet, and airborne precautions, including the use of eye protection. 3. On 02/02/22 at 3:10 PM, Surveyor #3 observed Resident #15 in bed with the head of bed slightly elevated. Resident #15 was alert and able to verbalize simple needs. At which time, the resident granted Surveyor #3 permission to observe the wound treatment. On 02/08/22 at 10:15 AM, Surveyor #3 observed the Licensed Practical Nurse (LPN), with the assistance of the RN/UM, complete the sacral wound dressing change for Resident #15. The RN/UM assisted the LPN to reposition the resident onto his/her left side. During the dressing change, Surveyor #3 observe the LPN cleanse the wound with gauze, ball the soiled gauze into a ball, touched the overbed table and curtain, then placed the soiled gauze into a plastic trash bag that was taped to the side of the overbed table. Surveyor #3 did not observe the LPN remove her gloves or perform hand hygiene after touching the overbed table and the curtain. The LPN continued the treatment and picked up a pair of scissors, opened an alcohol pad, wiped down the scissors, and opened/cut a piece of calcium alginate. Surveyor #3 observed the LPN touched the curtain as she placed the wrappers into the plastic trash bag. Surveyor #3 did not observe the LPN remove her gloves or perform hand hygiene after touching the curtain. The LPN continued the treatment and applied the calcium alginate to the resident's wound and covered it with border gauze. After the completing the sacral wound dressing change, the LPN removed her gloves and washed her hands. Surveyor #3 observed the LPN applied friction for five seconds outside the stream of water. When interviewed at that time, Surveyor #3 interviewed the LPN regarding her normal process for hand washing. The LPN stated the proper procedure for hand washing was to apply friction for 20 seconds outside the stream of water. The LPN further stated that she forgot to sing the Happy Birthday Song. During a follow up interview with Surveyor #3 on 02/08/22 at 10:29 AM, the RN/UM stated that she expected staff to apply friction for 20 seconds outside the stream of water. During an interview with Surveyor #3 on 02/08/22 at 12:23 PM, the Director of Nursing (DON) stated that she expected staff to turn on the water, wet hands, apply soap, and wash hands for 20 seconds of friction outside the stream of water. The DON further stated that proper hand washing was important for infection control and was the number one way to prevent the spread of infections. A review of the facility's undated Wound Care policy indicated that the licensed nurse would provide wound care using aseptic technique (using practices and procedures to prevent contamination from pathogens). The policy further indicated to use universal precautions on every resident to prevent cross-contamination. A review of the facility's undated Handwashing/Hand Hygiene policy indicated to create friction to all surfaces for 20 seconds under a moderate stream of running water. The CDC (Centers For Disease Control) Guideline for Hand Hygiene in Healthcare Settings recommends When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. NJAC 8:39-19.4

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to properly store medications within acceptable temperature ranges in accordance with manufacturer's guidelines. This deficient practice was identified for 1 of 2 medication rooms (Lower Willow Unit) reviewed as part of the medication storage and labeling task and was evidenced by the following: On 02/08/22 at 10:46 AM, the surveyors observed that the Lower Willow Unit medication storage refrigerator had a temperature reading of 42 degrees Fahrenheit (F). During an interview with the surveyors on 02/08/22 at 10:50 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that the morning-shift nurse noticed the refrigerator was unplugged earlier today. He further stated that she removed all medications from the refrigerator and stored them in the neighboring unit's medication refrigerator, until the affected refrigerator returned to an acceptable temperature range. He stated he was unsure for how long the refrigerator was unplugged and that he thought the highest temperature reached by the refrigerator was 45 F. According to the LPN/UM, none of the medications stored in this refrigerator were used except [MEDICATION(S)] 250 milligrams (mg)/5 milliliters (ml) Solution for Resident #64. [MEDICATION(S)] is a medication that is used to supplement the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the surveyors on 02/08/22 at 10:55 AM, the Licensed Practical Nurse (LPN) stated she noticed the refrigerator was unplugged when she came into work at 7:00 AM this morning. She checked the temperature at that time and recorded a reading of 80 F. The LPN moved the medications from the affected refrigerator to the neighboring unit's refrigerator until 9:33 AM, when the temperature of the previously unplugged refrigerator was deemed to be within acceptable storage range. The LPN clarified she did not know how long the refrigerator was unplugged or for how long it remained at the recorded temperature of 80 F. When asked by the surveyors, she stated that the medication can expire if it is out of its required storage temperature and acknowledged that the medication involved should probably not have been put back into the refrigerator for continued use. The LPN also advised the surveyors that she could find out the exact process for what should have been done in such a circumstance. When asked, she stated this incident was reported to LPN/UM earlier this morning, but she was not given any further instruction, aside from how she proceeded, as described. The surveyors reviewed the facility documentation titled, Medication Refridgerator [Refrigerator] to verify the recorded temperature of 80 F on 12/8 at 7:00 AM, with a noted temperature of 41 F as of 9:33 AM on the same day. During a follow-up interview with the surveyors on 02/08/22 at 11:10 AM, the LPN/UM confirmed that Resident #64 received [MEDICATION(S)] 250 mg/5 ml Solution as ordered this morning and there were no other medications given out of the affected refrigerator. The LPN/UM described the process that should occur in the referenced situation was as follows: obtain the medications from the affected refrigerator, remove them, and store them in another refrigerator; then, try to determine how long the medications were out of appropriate temperature range, if possible. The LPN/UM stated that the LPN advised him that this process was completed earlier this morning. However, the LPN/UM acknowledged that he was unaware that the affected refrigerator temperature reached 80 F and that he must have misunderstood the situation earlier this morning, clarifying that he thought the temperature did not increase above 48 F at any point in time. He further acknowledged that he did not know how long the temperature remained at 80 F. The LPN/UM further stated that if the LPN noticed that the affected medications were warm, she should have removed them and repeated that he did not know how long the temperature of the affected refrigerator remained at 80 F, when asked by the surveyor. During an interview with the surveyor on 02/08/22 at 11:20 AM, the Director of Nursing (DON) addressed the process for dealing with deviations in medication refrigerator storage. She stated the medication should be removed from the affected refrigerator and stored in another refrigerator, until the affected refrigerator temperature returns to an acceptable range. She further stated there is no way of telling what the temperature was at any point in time, or for how long of a period it remained at a given temperature without seeing it, meaning there is no remote monitoring of medication refrigerator temperatures. As a result, the DON stated it was important to immediately look at all items in the refrigerator and review the required temperatures and any permissible deviations of temperature for each of the items. If there is any uncertainty as to the viability of the medication(s) involved, it is necessary to discard them, and obtain new supplies from the pharmacy. The process involved multiple staff members, including the LPN, LPN/UM, Assistant Director of Nursing (ADON), DON, and pharmacy staff. Finally, the DON acknowledged that if the process broke down, this would be a problem because the security (clarified as viability for use) of medication, cannot be determined and the affected medications may not be appropriate for use. During a follow-up interview with the survey team on 02/08/22 at 12:17 PM, the DON confirmed that all the medications in the refrigerator were discarded and in the process of being replaced by the pharmacy. She reiterated that this procedure was completed because there is no way of knowing how long the medications were out of the temperature range, there is no remote monitoring of refrigerator temperatures, and the affected medications were possibly deteriorated. A review of the Admission Record (Face Sheet) for Resident #64 did reveal diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's current 02/22 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the survey team on 02/09/22 at 11:04 AM, the DON and Administrator clarified the date on the refrigerator log, where the temperature of the affected refrigerator was recorded as 80 F. The referenced staff members advised the correct date was 2/8 of the current year, not 12/8 as documented. A review of the facility's Policy & Procedure: Medication Refridgeration [Refrigerator] Storage confirmed the storage of medication is a highly regulated and important subject, with the goal being safety of residents and the need for temperatures to be maintained at appropriate levels. The policy indicated a need to keep the refrigerator at temperatures between 36-46 F by checking the thermometer, which must be present, daily. A review of the manufacturer's guidelines for the storage of [MEDICATION(S)] 250 mg/ml Solution revealed that it should be stored in a refrigerator, with a temperature range between 36 F to 46 F. NJAC 8:39-29.4(h)

Complaint Intake: NJ 8Based on record review, interviews, and review of facility policy, it was determined that the facility failed to notify the family of a medication change for one of four (Resident #1) residents reviewed for notification of changes. Findings included: 1. The facility admitted Resident #1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's face sheet revealed Resident #1 was their own responsible party (RP). A review of the admission Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Resident #1 required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #1 required supervision for eating and physical help in part of bathing activity. A review of the nurse's notes written by Licensed Practical Nurse (LPN) #3, dated 08/13/2021, revealed LPN #3 received a call from Resident #1's family member stating that Resident #1 kept calling and saying they were going to die, and nobody cared about them. Resident #1 was noted to have increased anxiety that morning and was unable to be re-directed. The facility's Medical Doctor was notified, and a new order for [MEDICATION(S)] 125 milligram (mg) twice daily was ordered for mood behavior and anxiety. There was no documentation to indicate that LPN #3 discussed the new medication with the resident or that the family had been contacted to inform them of the new medication order. An interview on 09/24/2021 at 12:35 PM with Resident #1's family member revealed that they were not notified that Resident #1 was prescribed [MEDICATION(S)] 125 mg twice a day (BID) or the reason for the added medication. During an interview on 09/25/2021 at 1:53 PM, Licensed Practical Nurse (LPN) #3 stated that she did not remember Resident #1 or remember writing the nurse's notes on 08/13/2021. LPN #3 further stated that if there were any changes in medications, she would notify the power of attorney/responsible party and document in the nurse's notes who was contacted. LPN #3 stated that if the resident was their own responsible party, she would discuss the change of medication with the resident if the resident was mentally alert. The LPN further stated she would ask the resident if they wanted anyone notified in the family and document that information in the nurse's notes. During an interview on 09/25/2021 at 2:10 PM, the Director of Nursing (DON) stated that it was her expectation that the nurse calls the resident's RP or the first contact in the chart to notify them of any medication change and document it in the nurse's notes. The DON further stated that if the resident was their own RP, then the medication change would be discussed with the resident and documented in the nurse's notes. The facility would get permission from the resident to notify the first contact in the chart. The DON indicated that if they didn't reach the first contact, then they would try the second contact. A review of the facility's policy titled, Nursing Notification of Changes, revised on 06/29/2021, revealed, It is the policy of this facility to immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member of the following changes, in person, via telephone or via email. Procedure: 3. A need to alter treatment significantly (i.e., need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). New Jersey Administrative Code § 8:39-5.1(a)

Based on observation, interview and record review, it was determined that the facility failed to utilize identified safety interventions for fall prevention. As a result, Resident #2 fell , sustained a laceration on the forehead, was sent to the hospital and returned to the facility with sutures and pain requiring narcotic pain medication. This deficient practice was identified for Residents #2 and #4, 2 of 4 residents reviewed for falls, and was evidenced by the following: 1. During the initial tour on 8/1/13 at 10:55 a.m., the nurse said that Resident #2 had dementia and had fallen within the past 3 months, sustaining a laceration above the eye. The surveyor observed Resident #2 seated in a wheelchair during the lunch meal on 8/1/13 at 12:20 p.m. and on 8/2/13 at 8:22 a.m. during the breakfast meal in the main dining room. The surveyor reviewed documentation in the medical record and observed that Resident #2 had [DIAGNOSES REDACTED]. The resident had poor safety awareness and a history of falls with injury. The facility identified the resident as being at high risk for falls. An interdisciplinary progress note (IPN) dated 4/22/13 at 12:45 p.m. indicated the certified nursing assistant (CNA) had called the nurse to the resident's room. The CNA told the nurse that she had taken the resident to the bathroom, was going to transfer the resident, but the resident grabbed "into toilet" and attempted to stand up. The CNA attempted to release the resident's hand from the toilet seat and assist the resident back into the wheel chair. The CNA told the nurse the resident resisted and the "CNA had to guide the resident to the floor as the resident could not bear weight." The nurse wrote that upon entering the room, she observed the resident "sitting/leaning on floor, still holding onto the toilet seat" with the left hand. On 4/23/13, the resident's 1/16/13 plan of care for fall risk was updated with the new intervention "Assist with transfer of 2 person assist." The surveyor reviewed the 5/3/13 quarterly Resident Assessment Instrument (RAI) that identified that the resident was non-ambulatory, staff dependent for transfers, and only able to stabilize balance with the assistance of staff during transfers from the bed to the wheelchair. In an IPN dated 5/14/13 at 7:50 p.m., the nurse documented at approximately 2:55 p.m. she was called to Resident #2's room to help Resident #2 who had fallen. The resident sustained [REDACTED]. The resident was confused, yelling out and crying. The resident was assessed and sent out to the hospital emergency room . The 5/14/13 hospital emergency room records indicated the resident fell , hitting the right eyebrow, and sustained an open 3 cm laceration which required 3 sutures to repair. The resident was medicated with a 2 mg dose of Morphine (a narcotic pain medication) in the emergency room . The resident was subsequently discharged from the emergency room and returned to the facility with orders for wound care and pain medication. Documentation in an IPN dated 5/15/13 at 5:30 a.m. indicated the resident had returned to the facility at 10 p.m. the prior evening. The resident had 3 sutures on the right frontal head and was heavily sedated. The resident returned with emergency room physician orders [REDACTED]. Upon readmission to the facility on [DATE] at 10 p.m., a telephone verbal physician order [REDACTED]. The physician also ordered the sutures (3) were to be removed in 5 to 7 days. In addition, the physician ordered Tylenol-Codeine #3 300 mg -30 mg 1 tablet every 6 hours as needed for pain. The surveyor reviewed documentation on the 5/13 MAR and 6/13 MAR: Resident #2 was medicated with 17 doses of "as needed" Tylenol-Codeine #3 between 5/15/13 and 5/31/13 and 10 doses in 6/13. The surveyor reviewed the Incident/Accident Report concerning this fall which was dated 5/14/13 at 2:50 p.m. The report indicated the resident was being transferred by a CNA from the bed to the wheelchair when the CNA turned to ensure placement of the wheel chair was correct, the resident fell hitting the right side of the head. According to the CNA's statement documented on 5/14/13 at 2:46 p.m., the resident was trying to get out of bed and she (the CNA) transferred the resident from the bed to the wheelchair. The CNA documented she sat the resident up in bed to transfer into the chair. The CNA then moved the wheelchair closer to the resident's bed. As the CNA was moving the chair closer to the resident, the resident was tilting on the bed. "That is when patient fell out of bed." According to the fall investigation, the CNA transferred the resident by herself, not following the care plan intervention for the required 2 person assist for transfers. 2. Resident #3 had [DIAGNOSES REDACTED]. The 7/25/13 Resident Assessment Instrument identified the resident as severely cognitively impaired, needing extensive staff assistance in all activities of daily living and having a history of falls. A "Fall Risk Assessment," completed on dates that included 3/18/13 and 7/24/13, identified the resident as "high risk" for falls. The current care plan included a problem of "Falls" with interventions of "bed alarm when in bed" and "chair alarm when out of bed to wheelchair." According to the medical record, these interventions were put into place following the resident having falls. Nurses notes documented the resident attempting to get out of bed to wheelchair on 3/18/13 without help, and sliding to the floor without sustaining injury. Nurses notes also documented another fall on 4/20/13 that resulted in the resident sustaining abrasions. The current physician's orders [REDACTED]. On 8/1/13 at 12:30 p.m. the surveyor observed Resident #3 sitting in a wheelchair in the bathroom in the resident's room. The resident was alone and was not wearing anything. The surveyor observed the resident's clothing and incontinence brief on the floor in the corner of the bathroom. There was no chair alarm present. The surveyor went for staff assistance and the Certified Nursing Assistant (CNA) said the resident stripped his/her clothes off frequently throughout the day. The CNA attended to the resident at that time. While in the resident's room, the surveyor had observed another wheelchair folded up next to the resident's bed. This wheelchair had a chair alarm attached to it. Following being re-dressed, the CNA placed the resident in bed for a nap. There was no alarm attached to the resident. On 8/2/13 at 8:15 a.m. the surveyor observed the resident sitting in a hospital gown in a wheelchair in the room. A chair alarm was attached to the resident. At 8:25 a.m. a CNA dressed the resident and placed the resident in a different wheelchair. There was no chair alarm applied to the resident after being dressed and placed in the different wheelchair. The first wheelchair was folded and placed next to the resident's bed. The chair alarm remained on the folded up wheelchair while Resident #3 sat in the other wheelchair with no alarm. At 9:40 a.m. and 10:30 a.m. the surveyor observed the resident sitting in the wheelchair in the room. There was no chair alarm in place. At 11:15 a.m. the surveyor observed the resident wheel him/herself to the main dining room. The resident remained from that time throughout lunch time without the chair alarm being applied. Following lunch, the surveyor reported the lack of the chair alarm to the Assistant Director of Nursing. NJAC 8:39 - 27.1 (a)

Based on observation and record review, it was determined that the facility failed to follow established plans of care. As a result, Resident #2 fell , sustained a laceration on the forehead, was sent to the emergency room and returned to the facility with sutures and narcotic pain medication. This deficient practice was identified for Residents #1, #2, and #3, 3 of of 15 residents reviewed and was evidenced by the following: 1. Resident #2 had an ongoing care plan, initiated on 1/16/13, for risk for falls related to impaired balance, impaired mobility and use of a wheelchair. According to documentation on the care plan, Resident #2 was "lowered to the floor" by a Certified Nursing Assistant (CNA) on 4/23/13. A new intervention added to the resident's plan of care dated 4/23/13 was "Assist with transfer of 2 person assist." In addition, the resident had an ongoing care plan for Activities of Daily Living Performance Deficit related to limited physical mobility. The intervention initiated on 5/3/13 indicated that Resident #2 required the physical assistance of 2 people for transfers. According to documentation in the resident's medical record, on 5/14/13 at 2:50 p.m., Resident #2 fell out of the bed when a CNA attempted a 1 person transfer of the resident from the bed into a wheelchair. At the time of the fall, the plan of care indicated the resident should have been transferred by 2 persons instead of 1 person. The resident sustained [REDACTED]. Refer to F323 2. Resident #3 had a history of falls. A "Fall Risk Assessment," completed on dates that included 3/18/13 and 7/24/13, identified the resident as being at "high risk" for falls. The current care plan addressing the problem of "Falls" contained interventions that included "bed alarm when in bed" and "chair alarm when out of bed to wheelchair." On 8/1/13 and 8/2/13 the surveyor observed the resident both in bed and out of bed in a wheelchair. The alarms were not consistently in place per the care plan. Refer to F323 3. Resident #1 had bilateral knee contractures. The resident also and a history of pressure ulcers with a left lateral ankle pressure ulcer that had just healed on 7/2013. The surveyor reviewed the current care plan that addressed "Skin Conditions" and contained interventions that included "pressure relief in bed/chair, prevent skin to skin contact." On 8/1/13 and 8/2/13 the surveyor observed the resident both in bed and out of bed in a recliner. The pressure relieving interventions were not in place as per the care plan. Refer to F314 NJAC 8:39 - 11.2 (e) 1,2