Every finding on record at Little Brook Nursing and Convalescent Home

Based on interviews and review of pertinent documentation provided by the facility, it was determined that the facility failed to implement the facility's abuse policy to ensure that reference checks were completed for 37 of 37 employee files reviewed. This deficient practice was evidenced by the following: The surveyor reviewed 37 employee files, which revealed the following: 1. Employee#1's date of hire (DOH) was 11/4/24, did not have a previous employee reference on file. 2. Employee#2's DOH was 11/5/24, did not have a previous employee reference on file. 3. Employee#3's DOH was 11/29/24, did not have a previous employee reference on file. 4. Employee#4's DOH was 12/4/24, did not have a previous employee reference on file. 5. Employee#5's DOH was 12/5/24, did not have a previous employee reference on file. 6. Employee#6's DOH was 12/9/24, did not have a previous employee reference on file. 7. Employee#7's DOH was 12/26/24, did not have a previous employee reference on file. 8. Employee#8's DOH was 12/27/24, did not have a previous employee reference on file. 9. Employee#9's DOH was 1/3/25, did not have a previous employee reference on file. 10. Employee#10's DOH was 1/10/25, did not have a previous employee reference on file. 11. Employee#11's DOH was 2/15/25, did not have a previous employee reference on file. 12. Employee#12's DOH was 2/16/25, did not have a previous employee reference on file. 13. Employee#13's DOH was 2/24/25, did not have a previous employee reference on file. 14. Employee#14's DOH was 3/12/25, did not have a previous employee reference on file. 15. Employee#15's DOH was 3/20/25, did not have a previous employee reference on file. 16. Employee#16's DOH was 3/31/25, did not have a previous employee reference on file. 17. Employee#17's DOH was 4/9/25, did not have a previous employee reference on file. 18. Employee#18's DOH was 4/22/25, did not have a previous employee reference on file. 19. Employee#19's DOH was 4/24/25, did not have a previous employee reference on file. 20. Employee#20's DOH was 4/25/25, did not have a previous employee reference on file. 21. Employee#21's DOH was 5/20/25, did not have a previous employee reference on file. 22. Employee#22's DOH was 6/9/25, did not have a previous employee reference on file. 23. Employee#23's DOH was 6/30/25, did not have a previous employee reference on file. 24. Employee#24's DOH was 7/2/25, did not have a previous employee reference on file. 25. Employee#25's DOH was 7/18/25, did not have a previous employee reference on file. 26. Employee#26's DOH was 8/2/25, did not have a previous employee reference on file. 27. Employee#27's DOH was 8/4/25, did not have a previous employee reference on file. 28. Employee#28's DOH was 9/2/25, did not have a previous employee reference on file. 29. Employee#29's DOH was 9/15/25, did not have a previous employee reference on file. 30. Employee#30's DOH was 9/17/25, did not have a previous employee reference on file. 31. Employee#31's DOH was 9/22/25, did not have a previous employee reference on file. 32. Employee#32's DOH was 9/29/25, did not have a previous employee reference on file. 33. Employee#33's DOH was 10/6/25, did not have a previous employee reference on file. 34. Employee#34's DOH was 10/10/25, did not have a previous employee reference on file. 35. Employee#35's DOH was 10/15/25, did not have a previous employee reference on file. 36. Employee#36's DOH was 1/20/26, did not have a previous employee reference on file. 37. Employee#37's DOH was 2/11/26, did not have a previous employee reference on file. On 3/2/26 at 1:15 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that she hires all the staff that enter the building, and the Business office manager (BOM) would make sure that the references are complete. At that same time the surveyor interviewed the BOM who stated that she did not do the reference checks and no further explanation was provided. A review of the facility's Resident Abuse Prohibition Policy with a revised date of 1/26, included Prospective employee.references are checked .prior to hiring. NJAC 8:39-9.3(b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a physician's order for monitoring behaviors and side effects for a resident using psychotropic medication for 1 of 5 residents (Resident #3) reviewed for unnecessary medications.This deficient practice was evidenced by the following: On 3/2/26 at 09:30 AM, the surveyor observed Resident #3 during medication administration pass. The resident was alert and oriented and was able to take their medications independently. A review of Resident #3's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of activities, and low energy lasting at least two weeks), depressive episodes (a period of at least two weeks featuring persistent low mood, loss of interest (anhedonia), and symptoms like fatigue, guilt, or sleep changes that impair daily functioning), and disturbances, psychotic disturbance, and anxiety.A review of Resident #3's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 02/02/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact.A review of the Care Plan Report revealed the following:A focus Area for Mood and Behavior with a goal for the resident to have few episodes of behaviors and mood problems. With an intervention to monitor behavior episodes with the attempt to determine the underline cause for the behaviors. Document behaviors and potential cause of the behaviors. With a revision date of 02/22/26A focus area for antidepressant medications with a goal that the resident will be free from discomfort and adverse reactions related to anti-depressants with an intervention to monitor and document side effects every shift with a revision date of 02/27/26.A focus area for antipsychotic medications with a goal that the resident would be free from complications with the used of antipsychotic medications which include complications that included movement disorder, discomfort, hypotension, gait disturbances, constipation/impaction, and cognitive/behavioral impairment. With an intervention to Monitor/record occurrence of the target behavior symptoms, anxiety, and document per facility protocol with a revision date of 08/21/25A review of the February 2026 Order Summary Report (OSR) revealed the following:A Physician's Order (PO) dated 12/31/25 for Mirtazapine oral tablet 7.5 mg, give 1 tablet by mouth at bedtime for depression.A PO dated 12/31/25 for Quetiapine Fumarate Oral Tablet 25 mg, give 1 tablet by mouth at bedtime for major depressive disorder, recurrent, severe with psychotic.Additional review of the resident's OSR revealed no PO to monitor for behaviors and monitor for potential side effects from anti-psychotic medications. A review of the December 2025 OSR revealed the following discontinued Physician's orders:A PO dated 8/4/23 for Monitor for the following behaviors: withdrawal, refusal of care, crying every shift with a discontinued date of 12/26/25A PO dated 06/03/23 for observing closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea, or vomiting, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth and tongue) with a discontinued date of 12/26/25.On 03/02/26 at 12:15 PM, the surveyor interviewed the Registered Nurse (RN) who stated that all the residents who take psychiatric medications should have a physician's order to monitor both behaviors and potential side effects. She did not know why Resident #3 did not have an order to monitor both behaviors and potential side effects but stated that these orders are entered by the Director of Nursing. On 03/02/26 at 12:30 PM, the surveyor in the presence of the DON reviewed Resident #3's physician's orders. The DON acknowledge that Resident #3 was being administered both an antidepressant and an antipsychotic and had no orders to monitor behaviors and side effects. The DON further acknowledges that he should have added these physician's orders when the resident returned from an acute care facility back in December. The DON acknowledged that it was important to document both the resident's behaviors and if they were experiencing potential side effects. On 03/03/25 at 1:45 PM, the surveyor discussed the above concerns with the facility administration team that consisted of the Facility Owner, Business Manager, Operational Manager, and the Director of Nursing (DON).There was no additional information provided.The facility had no policies that address the monitoring of behaviors and potential side effects of psychiatric medication.N.J.A.C. 8:39-27.1(a)

Based on facility staff interviews and review of pertinent facility documentation, it was determined that the facility failed to provide a designated qualified Infection Prevention and Control Nurse effective 11/28/26 through 03/4/26 and onward. This deficient practice was evidenced by the following: Reference: (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) S483.80(b) Infection preventionist the facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must: S483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; S483.80(b)(2) Be qualified by education, training, experience or certification; S483.80(b)(3) Work at least part-time at the facility; and S483.80(b)(4) Have completed specialized training in infection prevention and control On 2/25/26 at 09:22 AM, the Licensed Nursing Home Administrator (LNHA) stated the facility did not have a designated Infection Preventionist (IP). The IP resigned effective November 28, 2025. On 3/3/36 at 10:48 AM, the surveyor interviewed the LNHA, who confirmed that the Director of Nursing (DON) was performing both the duties of the DON and the duties of the IP. She then acknowledged that the IP should be a designated part-time (pt) or full-time (ft) position. She further stated that the facility was in Covid outbreak 1/16/26 onset and last Covid + test was on 1/30/26. The outbreak was removed on 3/2/26 by the Public Health Epidemiologist. During survey 2/25/26 through 3/4/26, the facility was unable to provide Center for Disease Control and Prevention (CDC) certificate for the facility staff. On 03/3/26 at 11:55 AM, the surveyor interviewed the Facility owner who stated he was unaware that the IP needed to be designated PT or FT employee. A review of the facility's policy, Infection Prevention and Control Program reviewed on 8/24 and revised 6/26/25, revealed: Policy Explanation and Compliance Guidelines; 1. The designated IP/ designee is responsible for the oversite of the program and serves as a consultant to our staff on infectious diseases.implementing isolation precauti9ons, staff and resident exposures, surveillance and epidemiological investigation of exposures of infectious disease . 6. Antibiotic Stewardship, (c) The IP with oversight from the DON serves as a leader of the antibiotic stewardship program. A review of the facility's policy, Infection Surveillance Policy dated 3/2025, reviewed 2/2026, revealed: Policy Explanation and Compliance. the IP serves as the leader in surveillance activities, maintains documentation of incidents, findings and any corrective actions made by the facility and reports surveillance findings to the facilities Quality assessment and Assurance committee and public health authorities when required. A review of the facility policy, Antibiotic Stewardship-Review and Surveillance of Antibiotic use and outcomes reviewed 2024, revealed.The IP will review all antibiotic starts with in 48 hours to determine if continued therapy is justified, justified with needed intervention, or NOT justified. NJAC 8:39-19.1 (b), 19.4(d) (e)

Repeat deficiencyBased on observation, interview, and record review, it was determined that the facility failed a). failed to secure one (1) of two (2) medication carts and one (1) medication room and b). properly dispose of medications for one (1) of five (5) residents (Resident #6) observed during medication administration, and c). having a medication disposal system in the facility.This deficient practice was evidenced by the following: a). On [DATE] at 11:40 AM, the surveyor called a Licensed Practical Nurse (LPN#1) into a resident's room after observing a partially consumed medication (unidentifiable tablet) on an overbed table. After the nurse acknowledged that it was a medication, she was observed bringing the medication back to the medication cart to dispose, the surveyor observed that the medication cart was unlocked. The surveyor observed no residents in the vicinity of the medication cart. At that time, the surveyor interviewed LPN #1 who acknowledged that the medication cart should have been locked.On [DATE] at 11:45 AM, the surveyor observed LPN #1 looking through two medication carts but was unable to find a pill buster (medication disposal system). She called the facility Director of Nursing (DON) who was observed opening the medication room door that was not locked. The surveyor observed no residents in the vicinity of the medication room. At that time, the surveyor interviewed the DON who acknowledged that the medication room should have been always locked.On [DATE] at 12:30 PM, the surveyor observed LPN#1 while administering medications to a resident in the dining room, turned her back from the medication cart and walked across the room. The surveyor observed that the medication cart was not locked. At that time, the surveyor interviewed LPN#1 who acknowledged that she should have locked the medication cart prior to walking away from the cart.On [DATE] at 8:55 AM, the surveyor observed Registered Nurse (RN#1) administering medications to a resident in the dining room/activity room. RN #1 had her back turned from the medication cart. The surveyor observed that the medication cart was unlocked. At that time, the surveyor interviewed RN#1 who acknowledged that she should have locked her medication cart. The surveyor observed no residents in the vicinity of the medication cart. b). On [DATE] at 9:05 AM, the surveyor during medication administration pass observed RN#1 taking Resident #6's Blood Pressure which was 93/63 with a Heart Rate of 65. RN#1 acknowledge that the resident had a hold medication order for when the systolic blood pressure was lower than 110. The surveyor then observed RN#1 disposed the Metoprolol ER 25 mg which was crushed and mixed with apple sauce into the resident's trash bin. At that time, the surveyor interviewed RN#1 who stated that it was okay to dispose the medication into the resident's trash because it was crushed. After discussing if there was a potential that another resident could consumed the medication especially since it was in apple sauce, RN#1 stated that she should destroy the medication inside a pill buster.c). On [DATE] at 9:20 AM, the surveyor observed RN#1 bring the Metoprolol ER and another medication cup with medications that needed to be disposed inside a pill buster. RN#1 was observed looking through two medication carts for a pill buster. RN #1 was unable to find a pill buster and alerted the DON. The DON looked in the medication room and returned and told the surveyor that he couldn't find a Pill Buster. At that time, the surveyor interviewed the DON who stated that after he destroyed the unidentifiable medication that was found in the resident's room yesterday, he noted that the pill buster was expired. He stated he ordered a few new bottles from the pharmacy. The DON further stated that he should always have one at the facility and knows the dangers of improperly disposing of medications.On [DATE] at 9:30 AM, the surveyor observed the DON securing all medications for destruction in his office which was locked.On [DATE] at 12:30 PM, the DON told the surveyor that he received a few pill busters from the pharmacy. The surveyor observed the destruction of the two cups of medications.On [DATE] at 1:45 PM, the surveyor discussed the above concerns with the facility administration team that consisted of the Facility Owner, Business Manager, Operational Manager, and the DON.There was no additional information provided. A review of the facility's policy for Administering Medications that was undated [DATE] and was provided by the Operational Manager revealed the following: During administration of medications, the medication cart will be kept closed and locked when out of sight of medication nurse or aide. It may be kept in the doorway of the resident's room, with the open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or other passing by. NJAC: 8:39-29.4 (a) (h) (d)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to follow proper infection control practices for personal protective equipment (PPE) N95 masks to prevent the potential spread of infection as per facility requirement. This deficient practice was evidenced by the following: On 2/25/26 at 09:10 AM the survey team entered the facility for a recertification survey, at that time the team was greeted and told an N95 mask was required for entrance. All surveyors complied with this request. The team coordinator asked if there were Covid positive (+) cases in the building and she was told there was not active Covid + in the building. On 2/25/26 at 09:15 AM, the surveyor observed the Licensed Nursing home administrator (LNHA) not wearing her facility required N95 respirator mask correctly. It was loosely fitted and worn on her chin while she was in the vestibule and resident day area. On 2/25/26 at 10:00 AM, during entrance the facility was asked again about Covid cases in the building, the LNHA did not inform the team that the facility was coming off Covid (+) outbreak ranging from initial case on 1/16/26 through last case on 1/30/26. On 2/26/26 at 11:04 AM, the surveyor observed the Licensed Nursing home administrator (LNHA) not wearing her facility required N95 respirator mask correctly. It was loosely fitted and worn on her chin while she was in the vestibule and resident day area. On 3/2/26 at 10:03 AM, the surveyor observed the Licensed Nursing home administrator (LNHA) not wearing her facility required N95 respirator mask. She was without the mask in the facility vestibule and nursing station area.On 3/2/26 at 12:04 PM, the surveyor observed the Social Worker (SW) not wearing her facility required N95 respirator mask correctly. It was loosely fitted and worn on her chin while she was in the vestibule and resident day area. On 3/02/2026 at 12:04 PM, the surveyor interviewed the SW, she was not wearing her facility required N95 mask. She was sitting at a community table in the resident day area doing paperwork. When surveyor questioned why she was not wearing her mask, she stated, there is no covid in the building at this time, she was not sitting directly with residents and felt it did not need to be pulled above her nose. On 3/02/2026 at 12:10 PM, the surveyor interviewed the LNHA, who stated whether you are an employee or visitor, the facility requires you to wear a respirator N95 mask for entire shift. If you are outside on the patio or deck it does not need to be worn above their nose and secured correctly. On 3/03/2026 at 1:04 PM, the surveyor interviewed the owner of the facility who stated, he is aware now that the Infection Preventionist resigned effective 11/28/26. He further stated that all the staff (including the LNHA and SW) are required to wear the N95 respirator mask in the facility. Wearing a mask is 95% effective if it is worn properly, if you are in the medical field and have gone through Covid, they should know how to wear a respirator N95 mask. A review of the facility's policy, Infection Prevention and Control Program reviewed on 8/24 and revised 6/26/25, revealed: Policy Explanation and Compliance Guidelines; 2. All staff are responsible for following all policies and procedures related to the program.4 (c) all staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. NJAC 8:39 - 19.4(a)

Based on interview and review of the facility documentation, the Quality Assurance and Performance Improvement (QAPI) committee failed to hold quarterly meetings for 2 of four Quapi meetings conducted.This deficient practice was evidenced by the following: On 2/25/26 at 10:35 AM, during the entrance conference, the surveyor requested the sign sheets for the past four quarters of the QAPI committee meetings. On 3/3/26 at 12:17 PM, the surveyor reviewed the attendance sheets along with the QAPI book. The book was divided into 9/10/24, 3/18/25 and 7/23/25. The review revealed that there were more than 3 months between each meeting.On 3/4/26 at 10:32 AM, the surveyor interviewed the Business Office Manager (BOM), who attended the QAPI meetings, who stated most of the time the facility had a quarterly meeting and sometimes the medical director goes on vacation so there would be delay in having the meetings. She further stated that the facility is aware that the medical director must be at the meetings. She further stated that the facility was scheduled and ready to have the meeting on 2/25/26 when the survey team came to the facility so that meeting was also canceled.On 3/4/26 PM at 12:00 PM, the surveyor interviewed the facility owner and the BOM who stated that they had to have had another meeting but were unable to find the sign in sheet and the meeting information. The BOM stated that the meetings should be held quarterly.Review of the facility's QA plan and Policy dated 5/20, revealed that the policy is intended to ensure the facility develops a plan that describes the process of conducting QAPI/QAA activities.which leads to improvement on the lives of the residents, through continuous attention to quality of care, quality of life, and resident safety. The policy failed to address the requirement of holding quarterly meetings.NJAC 8:39-33.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure meals were served at a safe and palatable temperature.This deficient practice was evidenced by the following:On 3/2/26 at 10:30 AM, the surveyor conducted the Resident Council meeting with four alert and oriented residents (Resident #3, #8, #16, and #27), selected by the facility to attend. During the meeting, all four residents in attendance stated that the food temperatures were not palatable: the hot foods were not hot, and the cold foods were not cold. On 3/2/26 at 12:18 PM, the surveyor calibrated a state-issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the Food Service Supervisor(FSS). At 12:20 PM, the surveyor and FSS observed that the food truck arrived at the unit. A regular diet consistency tray was identified by the surveyor. This tray was removed from the food truck and placed at the nurse's station in the presence of the surveyor and FSS. The FSS replaced the resident's tray from the kitchen.At 12:30 PM, the last tray was delivered to the residents, and the surveyor tested the food temperatures with the reserved tray in the presence of the FSS. The temperatures were as follows:Diced carrots 133.8 Fahrenheit (F)Salad 58.8 FFruit Cup 49.7 FAt 1:00 PM, the surveyor interviewed the FSS. The FSS stated that their kitchen equipment to maintain meal temperatures was working adequately and all the items on the lunch tray were within normal temperature limits prior to leaving the kitchen, but the passing out of the lunch trays caused the food items to lose their temperature. The FSS stated that the facility had no policy or procedure for the preparation or temperatures of foods. The FSS also stated that he had never checked the temperatures of a test tray. The only temperatures ever taken were in the kitchen before the food was delivered to the unit. On 3/3/26, the office manager provided the surveyor with the facility policy titled Food: Preparation, with a revised date of 9/2017. Dining Services Director/Cooks will be responsible for food preparation techniques which minimize the amount of time food items are exposed to temperatures greater than 41 degrees F and or less than 135 degrees F. Foods should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction. On 3/3/26 at 2:14 PM, the survey team met with the Director of Nursing (DON), facility owner, business manager, and office manager to discuss the above observations and concerns. On 3/4/26 at 10:15 AM, no further information was provided. NJAC 8:39-17.4(a) (2)

Based on observation, interview, and record review, it was determined that the facility failed to maintain respiratory care and equipment for a resident who was receiving continuous oxygen for 1 of 1 resident (Resident #6). This deficient practice was evidenced by the following: On 2/25/26 at 10:33 AM, the surveyor observed resident #6, in bed watching television. The resident was wearing a nasal cannula (NC) that was attached to a humidification water bottle and oxygen (O2) concentrator. Neither item was properly labeled or dated. The O2 concentrator was set at 3 L/min (liters per minute). On 2/26/26 at 10:08 AM, surveyor observed the resident out of bed in a wheelchair eating breakfast. The resident was wearing a NC that was attached to a humidification water bottle and O2 concentrator. Neither item was properly labeled or dated. The O2 concentrator was set at 3 L/min (liters per minute) . On 2/26/26 at 10:08 AM, the surveyor reviewed the electronic medical records (eMR) for Resident #6. A review of the admission record (an admission summary), reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to: chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that obstructs airflow to the lungs), chronic respiratory failure (CRF) with hypoxia (ARF is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). A review of the Minimum Data Set (MDS) reflected a Brief Interview for Mental Status (BIMS) score of 13 of 15 revealed that resident #6 cognitive skills for daily decision making were cognitively intact.A review of the Care Plan revealed a focus of oxygen therapy related to (r/t) COPD and chronic respiratory failure, dated 1/28/26. Including an intervention of delivery O2 via nasal cannula. A review of the Physician Order (PO) Summary Report reflected a PO dated 2/8/26 for Oxygen via Nasal Cannula (N/C) continuous every shift at 3 L/min for shortness of breath (SOB). Further review of the PO summary report revealed an order dated 2/8/26 for tubing and humidifier change one time a day on Mondays. On 2/26/26 at 11:40 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the nursing staff are supposed to follow the physician orders and facility policy for all O2 equipment changes. The DON further stated that while changing the equipment should be labeled and dated to ensure that it was completed and would allow other staff to know how old it is. The DON stated that it is to prevent contamination and infection.On 3/3//26 at 11:31 AM, the surveyor interviewed Resident #6 assigned Registered Nurse (RN), who stated tubing should be changed weekly and labeled as well as the humidification water. It should be done to prevent contamination and infection. The RN admitted the tubing was not labeled or dated. On 3/4/26 at 12:00 PM, the surveyor reviewed the undated policy Respiratory equipment which revealed, respiratory care equipment used in patient care will be stored in such a manner as to maintain the cleanliness and use of the equipment. On 3/4/26 at 12:40 PM, the survey team met with the office manager and owner of the facility. The facility did not provide any further information or policies. NJAC 8:39-11.2 (b); 27.1(a)

Repeat Deficiency Based on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a.) to have a resident rinse their mouth after inhaling a steroid inhaler per manufacturer specification observed in one (1) of five (5) residents observed during medication administration (Resident#21) and b.) to ensure that medication is properly stored for one (1) of nine (9) residents (Resident #9) reviewed.The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. a). On 3/2/26 at 09:05 AM, the surveyor observed Resident #21 seated in a chair and was watching television in the front activity room.On 3/2/26 at 9:10 AM, the surveyor observed a Registered Nurse (RN#1) preparing two (2) medications for Resident #21. RN #1 prepared one (1) tablet of Metformin 500 mg (blood sugar) and prepared an Fluticasone-Salmeterol 500-50 inhaler for administration. RN#1 in the presence of the surveyor read the directions for the inhaler and stated 1 puff inhale orally two times a day for COPD. Rinse mouth after each use. The surveyor then observed RN #1 administered both medications including the inhaler but never asked the resident to rinse their mouth after the inhaler was administered.At that time, the surveyor in the presence of RN#1 reviewed the directions for Fluticasone-Salmeterol 500-50 inhaler. RN#1 acknowledge that she should have asked the resident to rinse their mouth after inhaling the medication. A review of the admission record (admission summary) reflected that Resident #21 was admitted to the facility with diagnoses that included chronic diastolic (congestive) heart failure (occurs when the left ventricle becomes stiff and cannot fill properly, despite normal contraction), anxiety disorder( mental health conditions marked by excessive, persistent worry and fear that significantly disrupt daily life), and hypertension (the force of blood against the artery walls is consistently too high). A review of the quarterly Minimum Data Set, an assessment tool used to facilitate care, dated 02/13/26, reflected that the resident's cognitive skills for daily decision-making score was 4 out of 15, which indicated that the resident's cognition was severely impaired.A review of the March 2026 Order Summary Report (OSR) revealed the following Physician's Order (PO) dated 11/27/25 for Fluticasone-Salmeterol inhalation aerosol powder breath activated 500-50 mcg/act, 1 puff orally two times a day for COPD (chronic obstructive pulmonary disease). Rinse mouth after every use.A review of the March 2026 electronic medication administration record (e-MAR) revealed the following Physician's Order (PO) dated 11/27/25 for Fluticasone-Salmeterol inhalation aerosol powder breath activated 500-50 mcg/act, 1 puff orally two times a day for COPD (chronic obstructive pulmonary disease). Rinse mouth after every use. A further review of the e-MAR revealed a plotted time of 0900 (9:00 AM) and 1700 (5:00PM).b). On 2/25/26 at 10:30 AM, the surveyor observed Resident #9 during initial tour self-ambulating in the dining/activity room. The surveyor observed the recreational director re-directing the Resident #9.On 2/25/26 at 11:30 AM, the surveyor during initial tour observed inside Resident #9's room an unidentifiable tablet that was partially chewed on the resident's overbed table. At that time, the surveyor went to get the resident's nurse a Licensed Practical Nurse (LPN#1) who was at her medication cart. The surveyor in the presence of LPN#1 entered the resident's room and at that time, LPN#1 acknowledge that there was an unidentifiable tablet on the overbed table. LPN#1 stated that she does not know where the tablet came from, but when she administers medication, she makes sure the resident swallow the whole all their medications. LPN#1 observed the nurse put on a pair of gloves and with a tissue paper picked up the tablet and brought it to the medication room for destruction.On 3/3/25 at 1:45 PM, the surveyor discussed the above concerns with the facility administration team that consisted of the Facility Owner, Business Manager, Operational Manager, and the Director of Nursing (DON).There was no additional information provided.A review of the facility's policy for Administering Medications that was undated 09/05/25 and was provided by the Operational Manager revealed the following: 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.NJAC 8:39-27.1 (a), 29.2 (b) (d), 29.4 (g)(h)(k), 29.7 (c)

Based on observation, interview, and record review, it was determined that the facility failed to label and date an enteral tube feeding container and water flush bag. This deficient practice was identified for 1 of 1 residents reviewed for enteral tube feeding, (Resident #2). This deficient practice was evidenced by the following:1. On 2/25/26 at 10:25 AM, the surveyor observed Resident #2 in bed with his/her eyes closed and an enteral feeding (a method of providing nutrition directly into the gastrointestinal tract.) machine running. The enteral feeding container and water flush (a method of providing water directly into the gastrointestinal tract.) bag both observed missing labels with resident's name, date and time the enteral feeding and water flush bag were hung and started.On 2/26/26 at 9:27 AM, the surveyor interviewed the Director of Nursing (DON), who stated all enteral feeding containers and water flush bags need to be labeled with the resident's name, date and times the enteral feeding and water flush bags were started. The surveyor reviewed the electronic medical record (E-mar) for Resident #2.A review of the admission Record (AR) reflected Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; dysphagia (swallowing difficulty), peripheral vascular disease (a progressive disorder of the blood vessels outside the heart and brain) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the admission Minimum Data Set (MDS), an assessment tool dated 2/6/26, reflected that Resident #2's Brief Interview for Mental Status (BIMS) was unable to be performed because the resident is rarely understood.A review of the February order summary report revealed a physician order (PO), dated 1/30/26, Enteral feeding order in afternoon for feeding start with Jevity 1.5 call at 1600 PM with speed of delivery 65 milliliters per hour (ml/hr) and continue until 1170ml will be delivered. An additional PO dated 2/4/2026, Give 250ml of clear water as bolus, every 8 hours for hydration.A review of Resident #2's Care Plan Report included a focus area that the resident has a tube feeding, with interventions that included: the resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders.On 2/26/26 and 3/2/26 the surveyor requested a facility policy for enteral feeding, but no policy was provided.On 3/3/26 at 2:14 PM, the survey team met with the DON, facility owner, office manager, and business manager to discuss the above observations and concerns.On 3/4/26 at 10:15 AM, no further information was provided. NJAC 8:39-25.2(c)2; 27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to provide a privacy bag for a resident with an indwelling urinary catheter. This deficient practice was noted in 1 of 1 resident's reviewed with FC, (Resident #2). This deficient practice was evidenced by the following:On 2/25/26 at 10:25 AM, the surveyor observed Resident #2 in bed with his/her eyes closed with an indwelling urinary drainage bag hung on the bed rail visible from the resident doorway; no privacy bag observed.The surveyor reviewed the electronic medical record (E-mar) for Resident #2.A review of the admission Record (AR) an admission summary, reflected Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; dysphagia (swallowing difficulty), peripheral vascular disease (a progressive disorder of the blood vessels outside the heart and brain) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).A review of the admission Minimum Data Set (MDS), an assessment tool dated 2/6/26, reflected that Resident #2's Brief Interview for Mental Status (BIMS) was unable to be performed because the resident is rarely understood. The MDS further revealed Resident #2 had an indwelling catheter.A review of the current Physician Order Summary Report (OSR) reflected a physician's order (PO) dated 2/25/26, Urinary Catheter Care every shift. On 2/26/26 at 9:27 AM, the surveyor interviewed the Director of Nursing (DON), who stated all urinary bags should have a privacy bag. The DON was unable to state why a privacy bag was not present for Resident #2.On 2/26/26 and 3/2/26 the surveyor requested a facility policy for foley catheters, but no policy was provided.On 3/3/26 at 2:14 PM, the survey team met with the DON, facility owner, office manager, and business manager to discuss the above observations and concerns.On 3/4/26 at 10:15 AM, no further information was provided. NJAC 8:39-19.4 (a)4,5,6

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure that a specialty low air loss mattress was accurately set and monitored according to the resident's weight for 3 of 7 residents (Resident #1, #2, and #5, b.) failed to provide a resident with a pressure ulcer the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcer development for 1 of 3 residents reviewed for pressure ulcers (Resident #5). This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. A. 1. On 2/25/26 at 10:25 AM, the surveyor observed Resident #2 in bed with his/her eyes closed and a specialty mattress in place. The resident's air mattress pump was set to a weight of 250 pounds (lbs). The surveyor reviewed the electronic medical record (E-mar) for Resident #2. A review of the admission Record (AR) reflected Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; dysphagia (swallowing difficulty), peripheral vascular disease (a progressive disorder of the blood vessels outside the heart and brain) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the admission Minimum Data Set (MDS), an assessment tool dated 2/6/26, reflected that Resident #2's Brief Interview for Mental Status (BIMS) was unable to be performed because the resident is rarely understood. A review of the current Physician Order Summary Review (OSR) revealed no physician order (PO) for a specialty mattress. A review of the current Treatment Administration Record (TAR) did not include any documentation indicating the specialty mattress was being monitored for function and proper placement. A review of the resident vitals sign revealed the resident's last known weight was 187 lbs on 1/31/26. On 2/26/26 at 9:27 AM, in the presence of the Director of Nursing (DON), the surveyor observed the air mattress pump set to a weight of 250 lbs. The DON stated all air mattresses should be set to the residents' current body weight (CBW). 2. a) On 2/25/26 at 10:35 AM, the surveyor observed resident #5 in bed with his/her eyes closed and a specialty mattress in place. The resident's air mattress pump was set to a weight of 450 pounds. On 2/26/26 at 9:32 AM, the surveyor observed resident #5 in bed with a specialty mattress in place. The resident's air mattress pump was set to a weight of 450 pounds. The surveyor reviewed the medical record for Resident #5. A review of the admission Record reflected Resident #5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; Alzheimer's Disease (a progressive, irreversible brain disorder that damages neurons), diabetes mellitus (a chronic metabolic disorder characterized by consistently high blood sugar levels). A review of the current OSR reflected an active (PO) for a low-air-loss mattress, with a check function every shift. The PO was transcribed on the TAR and signed by the nurses, which indicated the mattress was being monitored. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 1/30/26, reflected that Resident #5's cognitive skills for daily decision making were severely impaired. The MDS further reflected that the resident's most recent weight was 135 pounds, had a stage 2 pressure ulcer, and had a pressure-reducing device for their bed and chair. A review of Resident #5's Care Plan Report included a focus area that the resident had pressure ulcers on the right and left buttocks, with interventions that included but were not limited to: provide a pressure-relieving mattress (low air loss mattress) on the bed and cushion when in a chair. On 2/26/26 at 10:40 AM, during an interview with the surveyor, the Registered Nurse (RN) confirmed that the specialty mattress was set at 450 pounds. The surveyor asked the RN the resident's weight. The RN confirmed that the resident's weight was 133 pounds and that she had signed the TAR, which indicated she had checked the mattress for function and proper placement, even though she had not. 3. On 02/25/26 at 10:40 AM, the surveyor observed Resident #1 in bed with their eyes open. The resident was aphasic (a disorder that affects communication) but was able to communicate with gestures (thumbs up) and pointing. The surveyor observed the specialty mattress with the pump set at 250 pounds. On 2/26/26 at 9:30 AM, the surveyor observed Resident #1 in bed on a specialty mattress with the pump set at 250 pounds. The surveyor reviewed the medical record for Resident #1. A review of the admission Record reflected the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to; hemiplegia (a severe paralysis affecting one side of the body) and hemiparesis (a neurological condition characterized by weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. A review of the current Physician OSR revealed no PO for a specialty mattress. A review of the current TAR did not include any documentation indicating the specialty mattress was being monitored for function and proper placement. A review of the quarterly MDS dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 8 out of 15, which indicated Resident #1 had a moderate cognitive impairment. The MDS further reflected that the resident weighed 152 pounds, was at high risk for pressure ulcer development, and had a pressure-reducing device on their bed. A review of the CP included a focus area: the resident has a potential impairment to skin integrity related to left hemiparesis and immobility, with interventions that included, but were not limited to: a pressure-relieving mattress to protect the skin while in bed. On 2/26/26 at 9:40 AM, the surveyor showed the DON the air mattress pump setting. The DON confirmed that the pump was set at 250 pounds. The DON confirmed that the specialty mattress was ordered to help prevent skin breakdown, so it should have been set at the resident's weight, which was 152. At the same time, the surveyor requested the specialty mattress policy and procedure from the DON. On 3/3/26 at 2:14 PM, the survey team met with the Director of Nursing (DON), the owner, the office manager, and the business manager to discuss the above observations and concerns. The DON confirmed that there should be POs for the specialty mattresses and that the nurses had signed the TARs, indicating they were responsible for monitoring the specialty mattresses and ensuring they were set to the Resident's weight. On 3/4/26 at 10:15 AM, no further information was provided. B. 2.) On 2/26/26 at 10:40 AM, the surveyor observed Resident #5 in bed with his/her eyes closed and a specialty mattress in place. The surveyor observed no signage on the door, indicating that the resident was under Enhanced Barrier Precautions (infection control measures in nursing homes and skilled nursing facilities, requiring gowns and gloves during high-contact resident care to reduce transmission of multi-drug-resistant organisms (MDROs), which applies to residents with wounds). The surveyor reviewed the medical record for Resident # 5. A review of the quarterly MDS, dated [DATE], reflected that Resident #5's Cognitive skills for daily decision-making were severely impaired. The MDS further reflected that the resident had a stage 2 pressure ulcer and had a pressure-reducing device for their bed and chair. The 2/12/26 Wound Care Note included documentation regarding the deep tissue bilateral buttock wound, which was currently unchanged. A review of the current Physician OSR reflected a PO dated 5/12/25, which included: Enhanced Barrier Precautions every shift for Wound; apply Desitin to sacrum area daily or as needed, dated 11/20/25, and a PO to apply Silicone border dressing twice daily, dated 5/22/25. On 2/26/26 at 11:22 AM, the surveyor observed the Registered Nurse (RN) perform the treatment to the resident's sacral pressure ulcer and observed the following: The RN sanitized the overbed table, gathered the supplies, which included a small amount of a zinc oxide barrier cream in a plastic cup,4x4 gauze pads, Normal Saline (NSS) bullets, and a silicone border dressing. The RN donned (put on) a disposable gown and gloves and placed all supplies on the overbed table. The Certified Nursing Assistant, without donning a gown, repositioned the resident. The RN removed the soiled foam dressing, which had a scant amount of brownish drainage. The RN discarded the soiled dressing, removed her gloves, washed her hands, and donned a new pair. The RN applied the NSS to the gauze and cleansed the wound from the peri-wound (tissue surrounding the wound) to the inner aspect of the wound, thereby contaminating the wound bed. The RN cleansed the wound again using the same technique, further contaminating the wound. The RN used an applicator to apply the zinc oxide barrier cream to the peri wound and, with the same applicator, to the wound bed, further contaminating the wound. The RN dated and initialed the Silicone Dressing and applied it to the wound. The RN did not remove the trash from the resident's room or sanitize the overbed table after the wound treatment was completed. On 2/26/26 at 11:55 AM, the surveyor discussed infection control breaches with the RN, who confirmed she should have removed the trash from the room and disinfected the overbed table after the treatment was completed. The RN stated that she was not aware that cleansing and applying the treatment to the peri-wound and then to the wound bed caused cross-contamination. On 2/26/26 at 12:00 PM, the surveyor interviewed the Director of Nursing (DON), who confirmed that Resident #5 had a PO for EBP and that signage should have been posted outside the room. The DON further stated that the CNA should have donned a gown, the RN should have cleansed and treated the wound from inside the wound bed to the peri wound, and should have disinfected the table after the wound treatment was completed. On 3/3/26 at 2:14 PM, the survey team met with the DON, facility owner, office manager, and business manager to discuss the above observations and concerns. A review of the facility's Wound Prevention policy and procedure dated 5/2020 reflected.all residents with wounds will have a pressure redistribution mattress. On 3/4/26 at 10:15 AM, no further information was provided. NJAC 8:39-19.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included smoking for 1 of 12 residents reviewed for Care Plans (Resident # 22). The deficient practice was evidenced by the following:On 2/25/26 at 9:30 AM, the surveyor observed Resident #22 awake in bed. The Resident stated that he/she was a smoker and that they were supervised while smoking.On 3/4/26 at 9:15 AM, the surveyor observed Resident #22 outside on the smoking patio with a staff member. The surveyor observed that Resident #22 was wearing a smoking apron.The surveyor reviewed the Medical Record for Resident #22.The admission Record reflected that Resident #22 was admitted to the facility with diagnoses that included but were not limited to; hypertension (high blood pressure) and alcohol induced dementia (a progressive neurological condition caused by long-term, heavy alcohol consumption that results in brain damage).A review of the admission Minimum Data Set (MDS), an assessment tool dated 2/24/26, reflected that Resident #22 had a brief interview for mental status of 15 out of 15, which indicated fully intact cognition. The MDS further reflected that the resident was a tobacco smoker.A review of the resident's Care Plan (CP) Report revealed that no CP was developed or implemented to plan and manage the resident's smoking. On 3/3/26 at 2:14 PM, the survey team met with the Director of Nursing (DON), the facility owner, the business manager, and the office manager to discuss the above observations and concerns.On 3/4/26 at 9:25 AM, during an interview with the surveyor, the DON confirmed that Resident #22 did not have a smoking CP but stated that all residents who smoke should have a Care Plan in place to ensure the resident's safety.A review of the facility's policy, Baseline Care Plan, undated reflected.It is the facility policy to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is used to plan and manage resident care, as evidenced by documentation from admission through discharge for each resident. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. On 3/4/26 at 10:15 AM, no further information was provided.NJAC 8:39-27.1(a)

Based on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms (Resident #16). The deficient practice was observed on 1 of 2 units during initial tour. The deficient practice was evidenced by the following: On 2/25/26 at 10:48 AM, the surveyor interviewed Resident #16 who was in his/her room, lying in bed. The surveyor observed Resident #16's call light plug taped into the wall outlet. Resident #16 stated the call light plug falls out of the outlet if it is not taped into the outlet, has been like that for over six months and the maintenance department is aware.On 2/26/26 at 9:30 AM, the surveyor and Director of Nursing (DON) entered Resident #16's room and both observed the resident's call light plug taped into the wall outlet. The DON stated he was not aware of any concerns in the resident's room but would alert maintenance. On 3/2/26 at 10:35 AM, the surveyor interviewed the facility's maintenance worker (MW#1) who stated, the facility had a logbook that the staff would use to list problems in resident rooms that needed to be fixed. MW #1 revealed he was aware of Resident #16's call light plug, and a request to fix the plug was put in the logbook on 4/29/25. MW#1 further stated that the maintenance department was waiting on a part so the outlet could be fixed. MW#1 stated that having to wait over eight months was an excessive amount of time and the outlet should have been fixed in a timelier fashion.On 2/26/26 and 3/2/26 the surveyor requested policies, but no policies were provided.On 3/3/26 at 2:14 PM, the survey team met with the DON, facility owner, office manager, and business manager to discuss the above observations and concerns.On 3/4/26 at 10:15 AM, no further information was provided.NJAC 8:39-4.1 (a)12

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 3 of12 residents reviewed for accommodation of needs (Resident #2, 5, and 28), and was evidenced by the following:1. On 2/25/26 at 10:25 AM, the surveyor observed Resident #2 in bed with his/her eyes closed. The surveyor observed the call bell cord was wrapped around the wall mounted receptacle not within the resident's reach. On 2/26/26 at 9:27 AM, in the presence of the Director of Nursing (DON), the surveyor observed the call bell cord wrapped around the wall mounted receptacle not within the resident's reach. The DON stated all call lights should be within reach of the resident. The surveyor reviewed the electronic medical record (E-mar) for resident #2. A review of the admission Record (AR) reflected Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; dysphagia (swallowing difficulty), peripheral vascular disease (a progressive disorder of the blood vessels outside the heart and brain) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the admission Minimum Data Set (MDS), an assessment tool dated 2/6/26, reflected that Resident #2's Brief Interview for Mental Status (BIMS) was unable to be performed because the resident is rarely understood. A review of Resident #2's Care Plan (CP) Report included a focus area that the resident was at risk for falls with an intervention to keep the call bell within the resident's reach. 2.On 2/25/26 at 10:35 AM, the surveyor observed Resident #5 in bed with his/her eyes closed. The surveyor observed that the call bell cord was wrapped around the wall mounted receptacle not within the resident's reach. On 2/26/26 at 9:32 AM, the surveyor observed resident #5 in bed with the call bell wrapped around the wall mounted receptacle not within the resident's reach The surveyor reviewed the medical record for Resident #5. A review of the admission Record reflected Resident #5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; Alzheimer's Disease (a progressive, irreversible brain disorder that damages neurons), diabetes mellitus (a chronic metabolic disorder characterized by consistently high blood sugar levels). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 1/30/26, reflected that Resident #5's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for activity of daily living (ADL) care. A review of Resident #5's Care Plan Report included a focus area that the resident was at high risk for falls with no intervention to keep the call bell within the resident's reach. On 2/26/26 at 10:40 AM, during an interview with the surveyor, the Registered Nurse (RN) confirmed that the call bell was not within the resident's reach but should have been. 3. On 2/25/2026 at 11:00 AM, the surveyor observed Resident #28 in bed with his/her eyes closed and call bell cord wrapped around and wall mounted receptacle not within the resident's reach. On 2/26/26 at 9:30 AM, the surveyor observed Resident #28 in bed with his/her eyes closed and the call bell cord wrapped around the wall mounted receptacle not within the resident's reach. The surveyor reviewed the medical record for Resident #28. A review of Resident #28's admission Record reflected the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to; dementia (progressive loss of intellectual functioning with impairment of memory) and Parkinson's Disease (a chronic progressive neurological disorder that causes the brain to lose dopamine-producing cells). A review of the quarterly MDS dated [DATE] reflected that the resident was dependent on staff for ADL care. A review of Resident #28's Care Plan Report reflected a focus area that included the resident had an ADL performance deficit with interventions that included but were not limited to; encourage the resident to use the call bell for assistance. On 2/26/26 at 9:40 AM, the surveyor showed the DON Resident #5 and Resident #28's call bells. The DON confirmed the call bells were not within the resident's reach, and that it was the responsibility of nurses and Certified Nursing Assistants to ensure the call bells were placed within the reach of all residents. On 3/3/26 at 2:14 PM, the survey team met with the DON, facility owner, office manager, and business manager to discuss the above observations and concerns. On 3/4/26 at 10:15 AM, no further information was provided. NJAC 8:39-27.1 (a); 31.8 (c) (9)

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 2/26/26 and 3/2/26, the surveyor observed one (1) nurse administer medications to five (5) residents. There were 26 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 11.54%. The deficient practice was identified for one (1) of five (5) residents, (Resident #6), that were administered medications by one (1) of one (1) nurse that were observed.The deficient practices were evidenced by the following:1). On 2/26/26 at 9:05 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN#1) entered the room of Resident #6. The surveyor observed RN#1 informing Resident #6 that she will be taking the resident's vitals and then will be administering the resident's medications. The surveyor observed the resident who was sitting on their bed and eating breakfast.On 2/26/26 at 8:42AM, the surveyor observed RN#1 preparing to administer eight (8) medications to Resident #6 which included one tablet of Aspirin EC (enteric coated) delay release 81 mg, Error #1 , one (1) tablet of Apixaban (atrial fibrillation) 2.5 mg, one vial of Budesonide 1mg/2ml inhalation (wheezing), one (1) vial of Arformoterol nebulizer 15 mcg/2ml (shortness of breath), one (1) capsule of Florastor 250 mg (supplement), one (1) tablet of Folic acid 400 mcg (anemia), one (1) tablet, of Metoprolol succinate ER (extended release) 25 mg (blood pressure), Error #2, and one (1) tablet of Sulfamethoxazole-Trimethoprim 800-160 mg (Bactrim DS) (antibiotic), Error #3 . The surveyor observed RN#1 crushing Metoprolol ER 25 mg and adding the contents in a medication cup with apple sauce. RN#1 was then observed crushing Folic acid, Abilify, Aspirin, Bactrim DS and adding the contents into a separate medication cup with apple sauce and the contents of the opened Florastor capsule. The nurse entered the resident's room, took the resident's blood pressure which was 93/63 with a heart rate of 65. The nurse held the Metoprolol ER but before she administered the rest of the resident's medications the surveyor asked the nurse if she could leave the room with all the resident's medications.At that time, the surveyor interviewed RN#1 who was unaware that Metoprolol ER 25mg, Aspirin EC, and Bactrim DS could not be crushed. After asking the nurse if enteric coated and delayed release medications could be crushed, she acknowledges that these types of medications should not be crushed.A review of the admission Record (an admission summary) reflected that Resident #6 was admitted to the facility with diagnoses that included hypertension (a condition where blood force against artery walls in consistently equal or greater than 130/80), congestive heart failure (a chronic condition where the heart can't pump blood efficiently, causing blood to back up and fluid to build up in the lungs, legs, and body), and malignant neoplasm of the bladder (an umbrella term for severe cognitive decline (an abnormal growth arising from the bladder lining, most commonly urothelial carcinoma).A review of the admission Minimum Data Set, an assessment tool used to facilitate care, dated 12/15/25, reflected that the resident's cognitive skills for daily decision-making score was 11 out of 15, which indicated that the resident was moderately impaired.A review of the February 2026 Order Summary Report (OSR) revealed the following: A Physician's Order dated 2/8/26, for Metoprolol Succinate ER oral tablet extended release 24 hours 25 mg, give 1 tablet by mouth one time a day for hypertonia. Hold if SBP (systolic blood pressure) below 110, pulse below 60 per minute. Notify MD.A PO dated 2/8/26, for Sulfamethoxazole-Trimethoprim oral tablet 800-160 mg, give 1 tablet by mouth one time a day for MRSA (Methicillin Resistant Staphylococcus Aureus) prophylaxis.A PO dated 2/8/26, for Aspirin EC oral tablet delayed release 81 mg, give 1 tablet by mouth one time a day for prophylaxis. Give with food.A review of the February 2026 Electronic Medication Administration Record (e-MAR) which revealed the following: A Physician's Order dated 2/8/26, for Metoprolol Succinate ER oral tablet extended release 24 hours 25 mg, give 1 tablet by mouth one time a day for hypertonia. Hold if SBP (systolic blood pressure) below 110, pulse below 60 per minute. Notify MD. The e-MAR further revealed a plotted time of 0900 (9:00 AM) which revealed that on 2/26/26 that RN#1 documented the residents BP as 93/63 with a pulse of 65 and the medication was held.A PO dated 02/08/26, for Sulfamethoxazole-Trimethoprim oral tablet 800-160 mg, give 1 tablet by mouth one time a day for MRSA (Methicillin Resistant Staphylococcus Aureus) prophylaxis. The e-MAR further revealed a plotted time of 0900 (9:00AM)A PO dated 2/8/26, for Aspirin EC oral tablet delayed release 81 mg, give 1 tablet by mouth one time a day for prophylaxis. Give with food. The e-MAR further revealed a plotted time of 0900 (9:00 AM). A review of Manufacturer's specifications revealed the following:Metoprolol Succinate Extended-Release should not be crushed or chewed, as this will destroy the special coating designed to release the medication slowly and will cause a dose dumping that could significantly increasing side effects and making the medication less effective. Aspirin EC delayed release tablets should never be crushed, chewed, or broken because coating is designed to prevent medication from dissolving until it reaches the small intestine. Crushing would cause medication to dissolve in the stomach and could lead to severe gastric irritation, stomach upset, or potential ulcers. Sulfamethoxazole-Trimethoprim should be swallowed whole with water. Do not crush or chew it. On 3/3/26 at 1:45 PM, the surveyor presented the above concerns to the facility owner, Director of Nursing, Office Manager, and Business Manager.No further information was provided.A review of the facility's policy for Administering Medications that was undated 9/5/25 and was provided by the Office Manager revealed the following: 3. Medications must be administered in accordance with the orders, including any required time frames. 7. The individual administering the medications must check THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administering before giving the medication. NJAC 8:39-11.2(b), 29.2(a)(d)

Complaint #: NJ00185571 Based on observation, interviews, and review of pertinent facility documents on 07/01/2025 and 07/02/2025, it was determined that the facility failed to implement a physician-ordered intervention to supervise and provide safety to residents from physical abuse by another resident (Resident #7,) who has a known history of aggressive behaviors towards other residents. The abuse occurred when facility staff failed to supervise, and to provide one-to-one (1:1) monitoring of Resident #7. This allowed the resident the opportunity to strike Resident #5 on the head with a metal object, causing laceration (cut) that required transfer to the hospital for treatment. This deficient practice was identified for Resident #7, 1 of 1 residents reviewed and was evidenced by the following: The surveyor reviewed the Facility Reported Event [FRE] dated 04/14/2025, which revealed that Resident #7 was observed striking Resident #5 with a grabber (a metal device used to assist residents grab items that are out of reach,) causing laceration that required transfer to the hospital for treatment. According to the FRE, the Certified Nursing Assistant (C.N.A.) who was assigned to provide one-to-one monitoring, left Resident #7 alone in the room to provide care for another resident. The FRE revealed that a Registered Nurse (R.N.) monitored Resident #7 from the hallway instead of within an arm's length as ordered. The facility's investigation into this incident showed that the R.N. monitored Resident#7 from 6 feet of the resident's room. According to the FRE, the C.N.A. heard commotion coming from resident's room and went to check the situation. Upon arrival to the room, the C.N.A observed Resident #7 striking his/her roommate (Resident #5) on the head with a grabber. At that time, the R.N. ran from the nurse's station to the resident's room and removed the grabber from Resident #7's hand and assessed both Resident #5 and #7. The R.N. then provided first aide treatment to Resident #5's cut and called the Emergency Services to take Resident #5 to the hospital for more treatment. The R.N. also called the local police department who came and took Resident #7 into custody. Resident#7 no longer resides at this facility.Review of the care plan in place at the time for Resident #7 revealed that the resident was to be on one-to-one (1:1) monitoring within an arm's reach.The staff's failure to provide one-to-one (1:1) monitoring placed Resident #5 and all other residents at harm for abuse and in an immediate jeopardy [IJ] situation. The IJ began on 04/14/2025 and was identified on 07/02/2025 at 3:50 P.M. and was reported to the Licensed Nursing Home Administrator [L.N.H.A.]. The L.N.H.A. was presented with the IJ template at the that time. An acceptable removal plan was mailed electronically on 07/08/2025, indicating the facility's actions to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice. The Director of Nursing (D.O.N.) provided education to all direct care staff, float staff and supervisors regarding the one-to -one (1:1) protocol, documentation and Abuse. The L.N.H.A. implemented an audit daily process for the supervisors to review for any 1:1 assignment and documentation. The L.N.H.A. also instituted a QAPI team weekly review to assess incident trends and compliance. The surveyor verified the removal plan on site on 07/10/2025After the IJ removal plan, the non-compliance continued 07/10/2025, at a scope and severity for no actual harm with the potential for more harm that was not an IJ. This deficient practice was identified for 1 of 1 residents [Residents #5] and was evidenced by the following:On 07/01/2025 at 9:30 A.M. the surveyor conducted a tour of the facility. The surveyor noted that the nurse's station is further than 6 feet from Resident #5 and #7's bedroom which would not have allowed the R.N. to be able to visually monitor into the room from the nurse's station and was not within an arm's length of the resident.The surveyor reviewed Resident #7's Progress note (PN) dated 04/14/2025 which confirmed that Resident #7 was to be on 1:1 monitoring while in his/her room. The PN further revealed that the assigned C.N.A left Resident #7 alone in the room with Residents #5, while the R.N. monitored from the nurse's station.A review of the closed medical admission Record [AR] for Resident #7 indicated that the resident was admitted to the facility with diagnoses which included but were not limited to Personality disorder, unspecified mood disorder, and unspecified psychosis.According to the Quarterly Minimum Data Set [MDS], an assessment dated [DATE], Resident #7 had a Brief Interview for Mental Status [BIMS] of 9 indicating the Resident #7 was moderately, cognitively impaired. Review of Resident #7's Care Plan [CP] initiated on 03/29/2025, with revisions on 04/06/2025 and 04/10/2025 revealed that Resident #7 was to have 1:1 monitoring by a staff member 24 hours/day until further notice. The CP reflected an updated intervention dated 04/06/2025 for side-by-side monitoring within arm's reach. The CP was revised again on 04/10/2025, to keep Resident #7 at arm's length to be able to get to him/her if him/her acts out aggressively to others. On 07/01/2025 the surveyor attempted to interview the R.N. that was on duty night of the incident and the D.O.N and L.N.H.A. stated that the R.N. was no longer employed with the facility.On 07/02/2025, the surveyor reviewed the employee files from the date of the event. The surveyor attempted to reach the R.N., and the number was not in service. The surveyor attempted to reach the C.N.A. but there was no return call to the surveyor.On 07/01/2025 at 2:194 P.M., the surveyor interviewed the D.O.N who stated that there should be an order for one-to-one (1:1) monitoring. She further defined one-to-one (1:1) monitoring as 1:1 is a specially dedicated person, need to be sitting next to the resident. The surveyor asked the DON for the difference between one-one (1:1) and one-to one (1:1) arm's length. The D.O.N. responded: I don't think there is a difference between one-to-one (1:1) and one-to-one (1:1) arm's length. The D.O.N. further stated that her expectation is staff is right next to the resident and that the staff do nothing but the one-to one (1:1.) She further stated that If someone needs the bathroom, other staff have to sit with the resident. The D.O.N. also stated that her expectation of the nurse was The nurse was near/next to him.On 07/01/2025 at 2:48 P.M. the surveyor interviewed the L.N.H.A. When asked about the expectations for a one-to-one (1:1), she stated: 1:1 is where the staff are within arm's length. You should be able to grab them, so they do not harm another resident. The L.N.H.A. further stated, Be with them at all times and that if the staff Need to use the restroom you need to call someone so they could sit with the resident. When the surveyor asked if monitoring from the nurse's station is considered one-to one (1:1) monitoring, she acknowledged that was not an arm's length. On 07/02/2025 at 2:39 P.M. the surveyor conducted a follow-up interview with the L.N.H.A. regarding the log for the one-to one (1:1) monitoring for the night of the event. She stated, I don't think so. When asked how the staff are trained for one-to-one (1:1) she replied that staff are trained through education. She stated that the R.N. and the C.N.A. were trained but no documentation was provided. She acknowledged that one-to-one (1:1) means staff is close to prevent the one-to-one (1:1) from harming.There is no evidence that the facility closely supervised Resident #7 as ordered by the physician.A review of the facility's policy titled Resident on Resident Abuse with a revision date 2024, revealed that the policy of the facility is to keep all residents free from all forms of abuse, mistreatment, neglect, and misappropriation of property from staff, visitors and other residents.N.J.A.C. 8:39-27.1(a)

Complaint #: NJ183318, NJ183964 Based on interviews, medical records review, and review of other pertinent facility documentation on 3/12/25 and 3/13/25, it was determined that the facility failed to thoroughly investigate an abuse allegation that involved a Certified Nursing Assistant (CNA #1) and Resident #1. The facility also failed to ensure its policy titled Abuse Investigations was implemented during the alleged abuse allegation. On 2/4/25 at approximately 12:40 P.M., the Licensed Nursing Home Administrator (LNHA) was notified by two representatives of the Ombudsman office that CNA #1 was trying to get Resident #1 out of bed, and the resident was screaming. The LNHA went to the resident's room, and Resident #1 told her that he/she did not want CNA #1 touching him/her. Resident #1 expressed to the LNHA and the Registered Nurse (RN #1) that CNA #1 pulled and hurt his/her left arm. RN #1 conducted a skin assessment that revealed bruising to Resident #1's left thumb. The LNHA stated she conducted an investigation and suspended CNA #1 immediately on 2/4/25. The LNHA did not conduct any resident interviews during the abuse investigation. The LNHA did not notify the local police of the abuse allegation. The LNHA concluded that CNA #1 was rough with Resident #1 but allowed CNA #1 to return to work on 2/7/25 after receiving sensitivity training and disciplinary action. After CNA #1 returned, she continued to work until 2/18/25, when she was terminated after a representative from the Ombudsman office reported to the LNHA that several residents had complained that CNA #1 was rough, would not help them and threatened to throw the residents in bed if they did not want to go to bed. The Ombudsman further reported to the LNHA that some residents felt unsafe around CNA #1. On 3/12/25, Resident #2 stated that CNA #1 had taken care of him/her in the past and stated the CNA often humiliated her and that he/she had reported it to the Ombudsman. The facility failed to follow its policies and procedures and protect facility residents by not conducting a thorough investigation into whether other residents had reports of abuse allegations involving CNA #1. This resulted in CNA #1 returning to work after a previous abuse allegation, which placed the residents being cared for by this staff member in an immediate jeopardy (IJ) situation. The IJ began on 2/7/25, was identified on 3/12/25 at 4:45 P.M., and was reported to the LNHA. The LNHA was presented with the IJ template at that time. An acceptable removal plan was electronically mailed to the surveyor on 3/17/25 at 3:27 PM, indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. CNA #1 was terminated from the facility on 2/18/25; the LNHA conducted an investigation into abuse allegations involving CNA #1, which included resident interviews; all facility staff were re-educated on the facility's abuse policy regarding when to report abuse allegations and to whom, the facility's owner re-educated the LNHA on the abuse and investigation sections of the abuse policy. The Director of Nursing (DON) conducted audits to see if any residents had experienced any form of abuse. The surveyor verified the removal plan on site on 3/18/25 and determined the IJ for F610 J was removed as of 3/18/25. After the IJ removal, the non-compliance continued from 3/18/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. This deficient practice was identified for 2 of 4 residents (Resident #1 and Resident #2) reviewed and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 2/4/25 revealed that Resident #1 screamed and started to kick CNA #1 as CNA #1 tried to transfer the resident into the chair to keep the resident from falling. The Ombudsman was visiting the facility and witnessed the encounter. The LNHA was notified of the incident by the Ombudsman. The LNHA immediately suspended CNA #1 and did an investigation. CNA #1 was suspended upon further investigation and was allowed to return to work with disciplinary actions and sensitivity training. On 2/18/25, the Ombudsman came to the facility and interviewed several residents who stated CNA #1 was rough, would not help them, and threatened to throw the residents in bed if they did not want to go to bed. The Ombudsman also reported that some residents felt unsafe. The LNHA terminated CNA #1 on 2/18/25. A review of the updated facility policy titled Abuse Investigations revealed under Policy Statement, All reports of resident abuse, neglect and injuries of the unknown source shall be thoroughly and promptly investigated by facility management. Under Policy Interpretation and Implementation, 3. The individual conducting the investigation will, as a minimum: i. Interview other residents to whom the accused employee provides care or services. 1. According to the Admission Record (AR), Resident #1 was admitted to the facility in September 2023 with diagnoses which included but were not limited to: Unspecified Dementia, Hyperlipidemia (high cholesterol), and Depression. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/24, Resident #1 had a blank space for the Brief Interview for Mental Status (BIMs) score. Under the Assessment section of the electronic medical record (EMR), Resident #1 had a BIMS score of 8 out of 15 on 3/11/2025, which indicated the resident's cognition was moderately impaired. The MDS further revealed that Resident #1 needed partial to moderate assistance with most Activities of Daily Living (ADLs). A review of Resident #1's February 2025 Progress Notes (PNS) dated 2/4/25 at 12:30 PM written by RN #1 revealed that the RN assessed Resident #1 for an incident involving CNA #1. Resident #1 told RN #1 that CNA #1 pulled and hurt his/her left arm. RN #1 observed bruising to the resident's left thumb. The resident complained of difficulty bending his/her left elbow and complained of 10 out of 10 pain to his/her arm. The surveyor was unable to reach RN #1 for an interview. The surveyor was unable to reach CNA #1 for an interview. 2. According to the AR, Resident #2 was admitted to the facility in 12/2024 with diagnoses which included but were not limited to: Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression, unspecified. According to the Quarterly MDS, an assessment tool dated 2/9/2025, Resident #2 had a blank space for the BIMS score. Under the Assessment section of the EMR, Resident #2 had a BIMS score of 15 out of 15 on 3/11/2025, which indicated the resident's cognition was intact. The MDS further revealed that Resident #2 was independent with most ADLs. On 3/12/2025 at 1:26 PM, the surveyor interviewed Resident #2, who stated CNA #1 had taken care of him/her in the past. According to Resident #2, CNA #1 was the only one who was not nice to her. CNA#1 caused her to feel frustrated and humiliated. Resident #2 indicated he/she did not report this to the facility staff because he/she did not want to make a big issue out of it, but he/she had reported this to the Ombudsman when they were at the facility. On 3/12/2025 at 2:14 PM, the surveyor interviewed the LNHA, who stated that the Ombudsman had notified her that CNA #1 was trying to get Resident #1 out of bed and that the resident was screaming. The LNHA indicated that Resident #1 told her that CNA#1 had pulled her arm and hurt it. Resident #1 stated that he/she did not want Resident #1 touching him/her. The LNHA stated she immediately suspended the CNA on 2/4/25 while she conducted an investigation. The LNHA further stated she concluded that CNA #1 was rough with Resident #1 and should have reapproached the resident. The LNHA indicated she allowed CNA #1 to return to work on 2/7/25 after conducting an investigation and provided the CNA with sensitivity training and disciplinary action with the hope there would be no further issues. The LNHA indicated that on 2/18/25, the Ombudsman informed her that several residents complained about how CNA #1 treated them. Some residents felt afraid when CNA #1 provided care to them, which resulted in the LNHA terminating the CNA on that day. The LNHA confirmed she did not interview or obtain statements from other residents in the facility. The LNHA could not speak to why she did not interview or obtain statements from other residents. The LNHA stated she did not call the police about the abuse allegation because she thought the police were only notified for serious injuries and elopements. The LNHA confirmed she did not notify the police about CNA #1 after the Ombudsman told her about the other resident complaints involving the CNA. The LNHA stated she did not follow up on the resident complaints she received from the Ombudsman because she ended up terminating CNA #1 on 2/18/25. On 3/12/2025 at 2:48 PM, the surveyor conducted a follow-up interview with the LNHA, who confirmed that part of the facility's abuse investigation policy included interviewing other facility residents about if they had experienced or witnessed any mistreatment from the staff member involved in an abuse allegation. The LNHA indicated she had never asked the Ombudsman who were the residents that had complaints involving CNA #1. The LNHA stated she should have interviewed the residents that CNA #1 had provided care to as part of her investigation. The LNHA stated it was important to conduct a thorough investigation into an abuse allegation to ensure the safety of all the residents. NJAC 8:39-4.1 (a) 5

Complaint #: NJ183318, NJ183964 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 3/12/25 and 3/13/25, it was determined that the facility failed to a.) update the care plan (CP) with interventions for a resident (Resident #1) involved in a staff to resident abuse allegation and b.) for residents (Resident #3 and #4) involved in a resident-to-resident incident. This deficient practice was identified in 3 of 3 residents reviewed for care plans and was evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility in September of 2023 with diagnoses which included but were not limited to: Unspecified Dementia, Hyperlipidemia (high cholesterol), and Depression. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/2024, Resident #1 had a blank space for the Brief Interview for Mental Status (BIMs) score. Under the Assessment section of the electronic medical record (EMR), Resident #1 had a BIMS score of 8 out of 15 on 3/11/2025, which indicated the resident's cognition was moderately impaired. The MDS further revealed that Resident #1 needed partial to moderate assistance with most Activities of Daily Living (ADLs). According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 2/4/25 revealed that Resident #1 screamed and started to kick CNA #1 as CNA #1 tried to transfer the resident into the chair to keep the resident from falling. The Ombudsman was visiting the facility and witnessed the encounter. The LNHA was notified of the incident by the Ombudsman. The LNHA immediately suspended CNA #1 and did an investigation. CNA #1 was suspended upon further investigation and was allowed to return to work with disciplinary actions and sensitivity training. On 2/18/25, the Ombudsman came to the facility and interviewed several residents that stated CNA #1 was rough, would not help them, and threatened to throw the residents in bed if they did not want to go to bed. The Ombudsman also reported that some residents felt unsafe. The LNHA terminated CNA #1 on 2/18/25. A review of Resident #1's CP revealed no new updates or interventions related to the abuse allegation that occurred on 2/4/25. 2. According to the AR, Resident #3 was admitted to the facility in March of 2024 with diagnoses which included but were not limited to: Diabetes, Depression, and Anxiety. According to the Quarterly MDS, an assessment tool dated 11/24/24, Resident #3 had a blank space for the BIMS score. Under the Assessment section of the EMR, Resident #3 had a BIMS score of 15 out of 15 on 3/11/25, which indicated the resident's cognition was intact. A review of Resident #3's CP initiated on 7/17/24 and revised on 9/21/24 revealed a Focus of Resident #3 has potential to be physically aggressive by biting other residents . 3. According to the AR, Resident #4 was admitted to the facility in June of 2024 with diagnoses which included but were not limited to: Personality Disorder (a mental health condition that involves disruptive patterns of thinking and behaviors), Hypertension, and Mood Disorder. According to the Quarterly MDS, an assessment tool dated 12/1/24, Resident #4 had a blank space for the BIMS score. Under the Assessment section of the EMR, Resident #4 had a BIMS score of 10 out of 15 on 3/10/25, which indicated the resident's cognition was moderately impaired. A review of Resident #4's CP initiated 11/23/24 and revised on 11/25/24 with a Focus of Resident #4 has a potential to be physically aggressive . According to the FRE, a NJDOH document used by healthcare facilities to report incidents with an event date of 12/17/24 revealed that Resident #3 and Resident #4 had a verbal argument while sitting at the dining room table. Resident #3 proceeded to self-propel himself/herself around the table in an attempt to bite Resident #4. The Activity Director attempted to intervene and witnessed Resident #4 push Resident #3 in the chest. Both residents were separated. A review of Resident #3 and #4's CP revealed no new updates or interventions related to resident-to-resident incident that occurred on 12/17/24. On 3/12/25 at 3:08 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the resident's CP should be updated when an incident occurs. The DON acknowledged the CP for Resident #1 was not updated and revised with new interventions after the 2/4/25 abuse allegation. The DON also acknowledged the CPs for Residents #3 and #4 were not updated and revised with new interventions after the 12/17/24 resident to resident incident. The DON stated she was responsible for updating the CPs but was not working in the facility when the abuse allegation and resident to resident incident occurred. The DON further indicated it was important to update the CPs to monitor the progression of the residents and help the staff know how to provide care to the residents. Review of the facility's undated policy titled Care Plan-Comprehensive revealed under Policy Statement, An individualized comprehensive care that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Under Policy Interpretation and Implementation, 8. 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 (e) (1) (2)

Complaint: NJ183318, NJ183964 Based on interviews, medical record reviews, and review of other pertinent facility documents on 3/12/25 and 3/13/25, it was determined that the facility failed to complete Section C of the Quarterly Minimum Data Set (MDS) and failed to follow its policy titled MDS for 6 of 6 sampled residents. This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility in September of 2023 with diagnoses which included but were not limited to: Unspecified Dementia, Hyperlipidemia (high cholesterol), and Depression. A review of Resident #1's Quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/24 under Section C0100 (Should a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces. 2. According to the AR, Resident #2 was admitted to the facility in December of 2024 with diagnoses which included but were not limited to: Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression, unspecified. A review of Resident #2's Quarterly MDS, an assessment tool dated 2/9/25 under Section C0100 (Should a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces. 3. According to the AR, Resident #3 was admitted to the facility in March of 2024 with diagnoses which included but were not limited to: Diabetes, Depression, and Anxiety. A review of Resident #3's Quarterly MDS, an assessment tool dated 11/24/24 under Section C0100 (Should a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces. 4. According to the AR, Resident #4 was admitted to the facility in June of 2024 with diagnoses which included but were not limited to: Personality Disorder (a mental health condition that involves disruptive patterns of thinking and behaviors), Hypertension, and Mood Disorder. A review of Resident #4's Quarterly MDS, an assessment tool dated 12/1/24 under Section C0100 (Should a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces. 5. According to the AR, Resident #5 was admitted to the facility in March of 2024 with diagnoses which included but were not limited to: Spinal Stenosis (narrowing of the spine), Diabetes, and Morbid Obesity. A review of Resident #5's Quarterly MDS, an assessment tool dated 12/29/24 under Section C0100 (Should a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces. 6. According to the AR, Resident #6 was admitted to the facility in September of 2024 with diagnoses which included but were not limited to: Congestive Heart Failure (a condition that affects the heart's ability to pump blood well), Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the airways), and Falls. A review of Resident #6's Quarterly MDS, an assessment tool dated 12/25/24 under Section C0100 (Should a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces. On 3/13/25 at 12:33 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the Social Worker (SW) was responsible for completing Section C of the MDS. The LNHA indicated the reason Section C was not completed was because the facility has not had a SW since November. The LNHA stated that the MDS Coordinator resigned at the end of February, but she was not responsible for Section C of the MDS, it was the SW's responsibility. The LNHA further stated it was important that all sections of the MDS were accurate to reflect the residents' care needs. A review of the facility's policy titled MDS with a revision date of 5/2024 revealed under Policy, Little [NAME] Nursing and Convalescent Home will adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure that a comprehensive and accurate assessment of residents will be completed . Under Procedure, 2.The following disciplines will be responsible to complete these sections: c. Section B, C, E, and Q completed by the Social Services Department. g. Sections C, D, GG, G (partial) . are entered into the computer software by the MDS Coordinator. NJAC 8:39-11.1

Part A Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure a cognitively impaired resident with a PO (physician's order) for NTL (nectar thick liquid, liquid thickened with an agent for a nectar like consistency) to prevent aspiration (accidental breathing in of fluid or food into the lungs). This deficient practice was identified for 1 of 18 residents reviewed for modified liquid diet consistency. On 10/23/24 at 12:28 PM, during lunch observation, the surveyor observed Resident #19 coughing while the Licensed Practical Nurse (LPN #1) was assisting Resident#19 with their meal. LPN #1 informed the surveyor that the resident started coughing after LPN #1 fed Resident #19 whole mandarin oranges in its own thin juice. LPN #1 stated that Resident #19 was on nectar thickened liquid. The surveyor observed thickened water, thickened coffee, and mandarin oranges in thin liquid juice on the resident's meal tray. The surveyor checked the meal card which revealed a plain yellow dot, and no specialized diet was identified. The surveyor asked LPN #1 what the yellow dot meant; LPN #1 did not know what the yellow dot meant and stated that the resident was on a mechanical soft diet (texture modified diet). The surveyor interviewed the Food Service Director (FSD) who stated that the kitchen staff plated the resident's meal tray, and that a yellow dot indicated a chopped diet (texture-modified). The FSD stated that a yellow dot with a N indicated NTL. Resident #19's meal card did not have a yellow dot with a N. The surveyor interviewed the MD [medical doctor] who confirmed that Resident #19 had a medical diagnosis of Parkinson's Disease (a movement disorder of the nervous system) and had a high risk of aspiration that could lead to pneumonia and death. The surveyor interviewed the Speech Language Pathologist (SLP), who revealed that the resident was on NTL and could not be served mandarin oranges in its own juice because the resident's vocal cords would not be able to close in time and the liquid would go into their lungs and cause aspiration. The facility's failure to ensure a cognitively impaired resident with a PO for NTL was provided the appropriate consistency diet posed a likelihood of choking and aspiration which could result in serious harm, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 10/23/24 at 12:28 PM, when Resident#19 was observed choking after being served whole mandarin oranges in thin liquid. The facility's Administration was notified of the IJ on 10/23/24 at 5:00 PM. The facility submitted an acceptable removal plan (RP) on 10/24/24 at 2:11 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 10/23/24. The evidence was as follows: A review of the facility Food Labels for Dietary Consistency policy with a review date of 2024, included food diets are marked by colored labels . yellow labels are soft chopped . yellow dot with N is nectar thick liquids . the colored dots are placed on the name cards and the tray cart . the color is changed if the diet is changed . On 10/23/24 at 12:28 PM, during the lunch observation, the surveyor observed Resident #19 coughing while LPN #1 was assisting the resident with their meal. LPN #1 informed the surveyor that the resident started coughing after LPN #1 fed Resident #19 whole mandarin oranges in its own thin juice. LPN #1 stated that Resident #19 was on nectar thickened liquid. The surveyor observed thickened water, thickened coffee, and mandarin oranges in thin liquid juice on the resident's meal tray. The surveyor checked the meal card which revealed a plain yellow dot and no specialized diet. LPN #1 stated they did not know what a yellow dot meant and added the resident was on a mechanical soft diet. On 10/23/24 at 12:35 PM, the surveyor interviewed the FSD who stated they plated Resident #19's meal tray and a plain yellow dot indicated a chopped diet and a yellow dot with a N indicated nectar thickened liquid. The surveyor did not observe a N on the resident's meal card. On 10/23/24 at 12:45 PM, the surveyor interviewed LPN #1 and LPN #2 who both stated they did not receive education regarding diet consistencies. On 10/23/24 at 1:19 PM, the surveyor interviewed the facility's MD, who was also Resident #19's primary care physician. The MD stated that the resident had a medical diagnosis which included Parkinson's Disease which contributed to a high risk of aspiration that could lead to pneumonia and death as a result. On 10/23/24 at 2:39 PM, the surveyor conducted a telephone interview with the Registered Dietician (RD) who confirmed that Resident#19 had a PO for NTL, and it was not appropriate for the resident to be served the whole mandarin orange in its own juice as it could lead to aspiration. On 10/23/34 at 3:24 PM, the surveyor interviewed the facility's SLP who stated the mandarin orange in its own juice cannot be served to a resident who was on NTL because the vocal cords would not be able to close in time and the liquid could go down their lungs and cause aspiration. On 10/23/24 at 1:10 PM, the surveyor reviewed Resident #19's electronic medical record. A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 7/21/24, reflected Resident#19 had a brief interview for mental status (BIMS) score of 3 out of 15, indicating that the resident had severe impaired cognition. A review of Section K revealed the resident received a mechanically altered diet. A review of the Admission Record face sheet (an admission summary) revealed that Resident #19 was admitted to the facility with diagnoses which included but were not limited to: Parkinson's Disease, unspecified abnormal involuntary movements, and unspecified dementia. A review of a PO dated 5/1/23, revealed a diet order for regular diet. mechanical soft texture, nectar/mildly thick consistency, chopped. A review of the individualized comprehensive care plan included a focus area dated 5/31/22, that the resident had a potential nutrition risk due to a mechanically altered diet. The goal included that the resident would tolerate their diet order without signs and symptoms (s/s) of aspiration. Interventions included to provide mechanical soft diet with nectar thickened liquids. A review of the key information section located in the electronic medical record revealed Special Instructions, Takes medications whole with nectar thickened liquids. A Review of the Physician's progress notes dated 8/3/24 at 3:02 PM, included the resident was seen and examined while seated in a chair. The resident was awake but confused with tremors and head movements. A review of the Speech Therapy (ST) Progress Notes (PN) documented by the SLP on 10/7/24 at 12:53 PM, included the resident was seen in their wheelchair in the dining room for dysphagia (difficulty swallowing) evaluation due to reported coughing during meals. The resident was currently on chopped diet with NTL with a recommendation to continue current diet. The recommendation was reviewed with nursing. A review of the Nutrition/Dietary quarterly note dated 10/19/24 at 8:11 AM, documented by the RD included the resident continued on a mechanical soft/chopped diet with NTL. The resident was seen by the SLP on 10/7/24, with no new diet orders, but it was recommended the resident be fed. On 10/23/24 at 5:00 PM, the survey team interviewed the LNHA, DON and Business Office Manager (BOM) who all confirmed Resident #19 should not have been fed the mandarin orange in thin juice since the resident was on a NTL diet. No further information was provided to the survey team. The acceptable RP on 10/24/24 at 2:11 PM, indicated the action the facility will have to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: Resident #19 was assessed by the Registered Nurse and MD; all nursing and kitchen staff were in-serviced on facility's consistency and added diet policy; any food with liquid consistency added such as sauce, gravies, natural juices and syrups will have added thickener for appropriate diet consistency and any diet changes will be communicated to the Charge Nurse who will communicate to the kitchen. The survey team verified the implementation of the RP during the continuation of the on-site survey on 10/24/24. 44605 Part B Based on observation, interview, record review, it was determined that the facility failed to accurately investigate the cause of a fall incident for 1 of 3 residents (Resident #15) reviewed for falls, and was evidenced by the following: On 10/22/24 at 10:45 AM, the surveyor observed Resident #15 seated in their wheelchair in their room with family present. Resident #15's family stated that the resident had a recent fall in the bathroom. The family member also stated that the facility notified them via telephone on the day of the fall incident. A review of Resident #15's Admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia, low back pain, and retention of urine. A review of a Quarterly Minimum Data Set, dated dated dated [DATE], revealed that the resident was unable to complete a Brief Interview for Mental Status (BIMS) due to severe memory impairment. A review of the progress note (PN) dated 9/25/24 at 5:28 AM, revealed that Resident #15 was found lying in the bathroom. The PN also indicated the nursing staff assessed the resident and obtained vital signs. A review of the Fall risk evaluation completed on 6/17/24, revealed that Resident #15 was at a moderate risk for falls. A review of the Physician Orders (PO) dated 9/25/24 revealed a PO for Right hip x-ray stat rule out (r/o) fracture. A review of Resident #15's comprehensive Care Plan (CP) revealed under focus with a revision date of 9/28/24 titled, The resident is at risk for falls r/t confusion, and had an unwitnessed fall with no injury. Further review of the CP included an intervention dated 9/28/24, to encourage resident to use call bell for help. On 10/24/24 at 9:46 AM, the surveyor interviewed the Director of Nursing (DON), who stated the facility does not complete fall investigation reports and any information regarding a fall incident would be documented under the nursing progress note found in the electronic medical record. The DON further added that there were no witness statements obtained after the fall. On 10/24/24 at 9:55 AM, the DON provided the surveyor a facility policy titled Falls, with an implementation date of 6/2024, under the policy section which revealed, All falls are to be investigated and monitored. The facility will maintain a record that contains a list of all incidents and falls. Under the program steps of the policy included, F . Complete Incident/Event Report. G. Start Investigation Report. H. Obtain detailed statements from any witnessed. Statements must be signed with the correct date and time for fall with serious injuries. On 10/24/24 at 12:21 PM, the survey team met with the Licensed Nursing Home Administrator (LHNA), DON and Business Office Manager (BOM) to review the above concern. The DON stated a complete fall investigation that included statements from witnesses was not completed for Resident #15's fall incident that occurred on 9/25/24. On 10/31/24 at 11:15 AM, the survey team met with the LHNA, DON, BOM and the Operator of the facility to discuss the above concern. There was no additional information provided. NJAC 8:39-27.1(a); 31.4(a); 33.1(d) NJAC 8:39-17.4 (a)1-2; 27.1(a)

Complaint #s NJ00155172, NJ00161276, NJ00160806, NJ00159306 Refer to F689, F756, F760, F835 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 118 of 119 day shifts, 54 of 119 evening shifts, and 10 of 119 overnight shifts. The failure of the facility to operate safely by following State minimum staffing requirements while continuing to admit new residents placed all residents at risk for serious harm, impairment or death. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties, and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. Nurse Staffing Reports were completed by the facility for 3 distinct periods of time equaling 17 weeks in total. The weeks of 8/28/2022-11/05/22 and 01/01/2023-02/04/2023 were reviewed due to complaints filed for low staffing during these 2 periods. A third period was reviewed for the 2 weeks of staffing prior to the standard recertification survey from 05/07/2023 to 05/20/2023, 1. For the 10 weeks of staffing from 08/28/2022 to 11/05/2022, the facility was deficient in CNA staffing for residents on 70 of 70 day shifts, deficient in total staff for residents on 35 of 70 evening shifts, deficient in CNAs to total staff on 2 of 70 evening shifts, and deficient in total staff for residents on 18 of 70 overnight shifts as follows: -08/28/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -08/28/22 had 2.5 total staff for 31 residents on the evening shift, required 3 total staff. -08/29/22 had 0.0 CNAs for 31 residents on the day shift, required 4 CNAs. -08/30/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -08/30/22 had 2.8 total staff for 31 residents on the evening shift, required 3 total staff. -08/31/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -08/31/22 had 2 total staff for 31 residents on the evening shift, required 3 total staff. -08/31/22 had 1.8 total staff for 31 residents on the overnight shift, required 2 total staff. -09/01/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -09/01/22 had 2.8 total staff for 31 residents on the evening shift, required 3 total staff. -09/01/22 had 1.3 total staff for 31 residents on the overnight shift, required 2 total staff. -09/02/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -09/02/22 had 2 total staff for 31 residents on the evening shift, required 3 total staff. -09/03/22 had 0.0 CNAs for 31 residents on the day shift, required 4 CNAs. -09/03/22 had 2.6 total staff for 31 residents on the evening shift, required 3 total staff. -09/04/22 had 1 CNA for 30 residents on the day shift, required 4 CNAs. -09/04/22 had 1.9 total staff for 30 residents on the evening shift, required 3 total staff. -09/04/22 had 0.9 CNAs to 1.9 total staff, required 1 CNA. -09/05/22 had 0.0 CNAs for 30 residents on the day shift, required 4 CNAs. -09/05/22 had 2.6 total staff for 30 residents on the evening shift, required 3 total staff. -09/07/22 had 0.0 CNAs for 30 residents on the day shift, required 4 CNAs. -09/07/22 had 2 total staff for 30 residents on the evening shift, required 3 total staff. -09/08/22 had 0.0 CNAs for 30 residents on the day shift, required 4 CNAs. -09/08/22 had 2.6 total staff for 30 residents on the evening shift, required 3 total staff. -09/09/22 had 0.0 CNAs for 30 residents on the day shift, required 4 CNAs. -09/09/22 had 2 total staff for 30 residents on the evening shift, required 3 total staff. -09/10/22 had 2 CNAs for 30 residents on the day shift, required 4 CNAs. -09/10/22 had 2 total staff for 30 residents on the evening shift, required 3 total staff. -09/11/22 had 1 CNA for 30 residents on the day shift, required 4 CNAs. -09/11/22 had 2 total staff for 30 residents on the evening shift, required 3 total staff. -09/11/22 had 1.5 total staff for 30 residents on the overnight shift, required 2 total staff. -09/12/22 had 0.0 CNAs for 30 residents on the day shift, required 4 CNAs. -09/13/22 had 1 CNA for 30 residents on the day shift, required 4 CNAs. -09/13/22 had 2.3 total staff for 30 residents on the evening shift, required 3 total staff. -09/14/22 had 0.5 CNAs for 30 residents on the day shift, required 4 CNAs. -09/15/22 had 0.8 CNAs for 31 residents on the day shift, required 4 CNAs. -09/15/22 had 2 total staff for 31 residents on the evening shift, required 3 total staff. -09/16/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -09/16/22 had 2.5 total staff for 31 residents on the evening shift, required 3 total staff. -09/17/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -09/17/22 had 0.0 CNAs to3 total staff on the evening shift, required 1 CNA. -09/18/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -09/18/22 had 2 total staff for 31 residents on the evening shift, required 3 total staff. -09/19/22 had 2 CNAs for 32 residents on the day shift, required 4 CNAs. -09/19/22 had 2 total staff for 32 residents on the evening shift, required 3 total staff. -09/19/22 had 1 total staff for 32 residents on the overnight shift, required 2 total staff. -09/20/22 had 2 CNAs for 32 residents on the day shift, required 4 CNAs. -09/21/22 had 2 CNAs for 32 residents on the day shift, required 4 CNAs. -09/22/22 had 1 CNA for 32 residents on the day shift, required 4 CNAs. -09/22/22 had 2 total staff for 32 residents on the evening shift, required 3 total staff. -09/23/22 had 1 CNA for 32 residents on the day shift, required 4 total staff. -09/24/22 had 2 CNAs for 32 residents on the day shift, required 4 total staff. -09/25/22 had 0.0 CNAs for 32 residents on the day shift, required 4 CNAs. -09/25/22 had 2 total staff for 32 residents on the evening shift, required 3 total staff. -09/26/22 had 1 CNA for 32 residents on the day shift, required 4 CNAs. -09/27/22 had 1 CNA for 32 residents on the day shift, required 4 CNAs. -09/28/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -09/29/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -09/29/22 had 2 total staff for 31 residents on the evening shift, required 3 total staff. -09/30/22 had 2 CNAs for 31 residents on the day shift, required 4 CNAs. -10/01/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -10/01/22 had 2 total staff for 31 residents on the evening shift, required 3 total staff. -10/02/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -10/02/22 had 2.6 total staff for 31 residents on the evening shift, required 3 total staff. -10/03/22 had 0.0 CNAs for 31 residents on the day shift, required 4 CNAs. -10/04/22 had 1.6 CNAs for 31 residents on the day shift, required 4 CNAs. -10/04/22 had 2 total staff for 31 residents on the evening shift, required 3 total staff. -10/05/22 had 2 CNAs for 33 residents on the day shift, required 4 CNAs. -10/06/22 had 2 CNAs for 32 residents on the day shift, required 4 CNAs. -10/07/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -10/07/22 had 2 total staff for 31 residents on the evening shift, required 3 total staff. -10/08/22 had 1 CNA for 31 residents on the day shift, required 4 CNAs. -10/09/22 had 0.0 CNAs for 31 residents on the day shift, required 4 CNAs. -10/09/22 had 1 total staff for 31 residents on the overnight shift, required 2 total staff. -10/10/22 had 2 CNAs for 30 residents on the day shift, required 4 CNAs. -10/11/22 had 2 CNAs for 30 residents on the day shift, required 4 CNAs. -10/12/22 had 2.9 CNAs for 30 residents on the day shift, required 4 CNAs. -10/13/22 had 1 CNA for 30 residents on the day shift, required 4 CNAs. -10/13/22 had 1 total staff for 30 residents on the overnight shift, required 2 total staff. -10/14/22 had 1.9 CNAs for 30 residents on the day shift, required 4 CNAs. -10/15/22 had 2 CNAs for 30 residents on the day shift, required 4 CNAs. -10/15/22 had 2 total staff for 30 residents on the evening shift, required 3 total staff. -10/15/22 had 1 total staff for 30 residents on the overnight shift, required 2 total staff. -10/16/22 had 1 CNA for 29 residents on the day shift, required 4 CNAs. -10/16/22 had 2 total staff for 29 residents on the evening shift, required 3 total staff. -10/16/22 had 1 total staff for 29 residents on the overnight shift, required 2 total staff. -10/17/22 had 1.9 CNAs for 29 residents on the day shift, required 4 CNAs. -10/17/22 had 2.6 total staff for 29 residents on the evening shift, required 3 total staff. -10/18/22 had 1.9 CNAs for 29 residents on the day shift, required 4 CNAs. -10/19/22 had 1.9 CNAs for 29 residents on the day shift, required 4 CNAs. -10/20/22 had 2 CNAs for 29 residents on the day shift, required 4 CNAs. -10/20/22 had 2.6 total staff for 29 residents on the evening shift, required 3 total staff. -10/21/22 had 2 CNAs for 29 residents on the day shift, required 4 CNAs. -10/22/22 had 1 CNA for 29 residents on the day shift, required 4 CNAs. -10/22/22 had 1.3 total staff for 29 residents on the overnight shift, required 2 total staff. -10/23/22 had 1 CNA for 28 residents on the day shift, required 3 CNAs. -10/23/22 had 2 total staff for 28 residents on the evening shift, required 3 total staff. -10/23/22 had 1 total staff for 28 residents on the overnight shift, required 2 total staff. -10/24/22 had 1 CNA for 28 residents on the day shift, required 3 CNAs. -10/25/22 had 2.9 CNAs for 28 residents on the day shift, required 3 CNAs. -10/26/22 had 2 CNAs for 28 residents on the day shift, required 3 CNAs. -10/27/22 had 1.9 CNAs for 28 residents on the day shift, required 3 CNAs. -10/28/22 had 1.9 CNAs for 28 residents on the day shift, required 3 CNAs. -10/28/22 had 2.5 total staff for 28 residents on the evening shift, required 3 total staff. -10/29/22 had 0.9 CNAs for 28 residents on the day shift, required 3 CNAs. -10/29/22 had 2 total staff for 28 residents on the evening shift, required 3 total staff. -10/29/22 had 1.3 total staff for 28 residents on the overnight shift, required 2 total staff. -10/30/22 had 0.8 CNAs for 28 residents on the day shift, required 3 CNAs. -1030/22 had 2.9 total staff for 28 residents on the evening shift, required 3 total staff. -10/30/22 had 1.1 total staff for 28 residents on the overnight shift, required 2 total staff. -10/31/22 had 0.4 CNAs for 27 residents on the day shift, required 3 CNAs. -10/31/22 had 1.3 total staff for 27 residents on the overnight shift, required 2 total staff. -11/01/22 had 0.9 CNAs for 27 residents on the day shift, required 3 CNAs. -11/01/22 had 1.5 total staff for 27 residents on the overnight shift, required 2 total staff. -11/02/22 had 1.7 CNAs for 27 residents on the day shift, required 3 CNAs. -11/02/22 had 1.1 total staff for 27 residents on the overnight shift, required 2 total staff. -11/03/22 had 0.8 CNAs for 27 residents on the day shift, required 3 CNAs. -11/03/22 had 2.3 total staff for 27 residents on the evening shift, required 3 total staff. -11/03/22 had 1.6 total staff for 27 residents on the overnight shift, required 2 total staff. -11/04/22 had 1.7 CNAs for 27 residents on the day shift, required 3 CNAs. -11/04/22 had 1.8 total staff for 27 residents on the overnight shift, required 2 total staff. -11/05/22 had 0.9 CNAs for 27 residents on the day shift, required 3 CNAs. -11/05/22 had 1.8 total staff for 27 residents on the overnight shift, required 2 total staff. 2. For the 5 weeks of staffing from 01/01/2023 to 02/04/2023, the facility was deficient in CNA staffing for residents on 34 of 35 day shifts, deficient in total staff for residents on 8 of 35 evening shifts, deficient in CNAs to total staff on 6 of 35 evening shifts, and deficient in total staff for residents on 6 of 35 overnight shifts as follows: -01/01/23 had 1 CNA for 29 residents on the day shift, required 4 CNAs. -01/01/23 had 1.4 CNAs to 3.4 total staff on the evening shift, required 2 CNAs. -01/01/23 had 1 total staff for 29 residents on the overnight shift, required 2 total staff. -01/02/23 had 1 CNA for 28 residents on the day shift, required 3 CNAs. -01/03/23 had 2.6 CNAs for 28 residents on the day shift, required 3 CNAs. -01/04/23 had 2.7 CNAs for 28 residents on the day shift, required 3 CNAs. -01/05/23 had 1.9 CNAs for 28 residents on the day shift, required 3 CNAs. -01/05/23 had 2.9 total staff for 28 residents on the evening shift, required 3 total staff. -01/06/23 had 2.2 CNAs for 28 residents on the day shift, required 3 CNAs. -01/07/23 had 1 CNA for 28 residents on the day shift, required 3 CNAs. -01/07/23 had 1 total staff for 28 residents on the overnight shift, required 2 total staff. -01/08/23 had 1 CNA for 28 residents on the day shift, required 3 CNAs. -01/08/23 had 2.7 total staff for 28 residents on the evening shift, required 3 total staff. -01/09/23 had 2 CNAs for 28 residents on the day shift, required 3 CNAs. -01/09/23 had 2.7 total staff for 28 residents on the evening shift, required 3 total staff. -01/10/23 had 0.6 CNAs for 28 residents on the day shift, required 3 CNAs. -01/11/23 had 1 CNA for 26 residents on the day shift, required 3 CNAs. -01/12/23 had 1 CNA for 26 residents on the day shift, required 3 CNAs. -01/12/23 had 1.7 CNAs to 3.5 total staff on the evening shift, required 2 CNAs. -01/13/23 had 1.6 CNAs for 26 residents on the day shift, required 3 CNAs. -01/14/23 had 1 CNA for 26 residents on the day shift, required 3 CNAs. -01/14/23 had 2.7 total staff for 26 residents on the evening shift, required 3 total staff. -01/14/23 had 1 total staff for 26 residents on the overnight shift, required 2 total staff. -01/15/23 had 1 CNA for 28 residents on the day shift, required 3 CNAs. -01/15/23 had 1.4 CNAs to 3.4 total staff on the evening shift, required 2 CNAs. -01/15/23 had 1 total staff for 28 residents on the overnight shift, required 2 total staff. -01/16/23 had 1 CNA for 28 residents on the day shift, required 3 CNAs. -01/17/23 had 1.2 CNAs for 28 residents on the day shift, required 3 CNAs. -01/18/23 had 1.9 CNAs for 28 residents on the day shift, required 3 CNAs. -01/19/23 had 1.2 CNAs for 29 residents on the day shift, required 4 CNAs. -01/19/23 had 1.9 CNAs to 3.2 total staff on the evening shift, required 2 CNAs. -01/19/23 had 1.1 total staff for 29 residents on the overnight shift, required 2 total staff. -01/20/23 had 2 CNAs for 28 residents on the day shift, required 3 CNAs. -01/20/23 had 2.6 total staff for 28 residents on the evening shift, required 3 total staff. -01/21/23 had 1 CNA for 28 residents on the day shift, required 3 CNAs. -01/21/23 had 2.4 total staff for 28 residents on the evening shift, required 3 total staff. -01/22/23 had 2.3 total staff for 28 residents on the evening shift, required 3 total staff. -01/23/23 had 2.8 CNAs for 28 residents on the day shift, required 3 CNAs. -01/23/23 had 1 total staff for 28 residents on the overnight shift, required 2 total staff. -01/24/23 had 2.9 CNAs for 27 residents on the day shift, required 3 CNAs. -01/25/23 had 1.5 CNAs for 27 residents on the day shift, required 3 CNAs. -01/26/23 had 2 CNAs for 27 residents on the day shift, required 3 CNAs. -01/26/23 had 2.2 total staff for 27 residents on the evening shift, required 3 total staff. -01/27/23 had 2.1 CNAs for 27 residents on the day shift, required 3 CNAs. -01/28/23 had 1.2 CNAs for 29 residents on the day shift, required 4 CNAs. -01/28/23 had 1.4 CNAs to 3.7 total staff on the evening shift, required 2 CNAs. -01/29/23 had 2 CNAs for 29 residents on the day shift, required 4 CNAs. -01/29/23 had 1.4 CNAs to 3.5 total staff on the evening shift, required 2 CNAs. -01/30/23 had 2.2 CNAs for 29 residents on the day shift, required 4 CNAs. -01/31/23 had 1.8 CNAs for 29 residents on the day shift, required 4 CNAs. -02/01/23 had 0.7 CNAs for 29 residents on the day shift, required 4 CNAs. -02/02/23 had 0.8 CNAs for 29 residents on the day shift, required 4 CNAs. -02/03/23 had 1 CNA for 29 residents on the day shift, required 4 CNAs. -02/04/23 had 1 CNA for 29 residents on the day shift, required 4 CNAs. 3. For the 2 weeks of staffing prior to survey from 05/07/2023 to 05/20/2023, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts, deficient in total staff for residents on 11 of 14 evening shifts, deficient in CNAs to total staff on 1 of 14 evening shifts, and deficient in total staff for residents on 2 of 14 overnight shifts as follows: -05/07/23 had 1 CNA for 28 residents on the day shift, required 3 CNAs. -05/07/23 had 2.5 total staff for 28 residents on the evening shift, required 3 total staff. -05/08/23 had 1 CNA for 27 residents on the day shift, required 3 CNAs. -05/09/23 had 0.7 CNAs for 27 residents on the day shift, required 3 CNAs. -05/09/23 had 2.4 total staff for 27 residents on the evening shift, required 3 total staff. -05/10/23 had 0.7 CNAs for 27 residents on the day shift, required 3 CNAs. -05/10/23 had 2.1 total staff for 27 residents on the evening shift, required 3 total staff. -05/10/23 had 0.9 CNAs to 2.1 total staff on the evening shift, required 1 CNA. -05/11/23 had 0.5 CNAs for 27 residents on the day shift, required 3 CNAs. -05/11/23 had 2.6 total staff for 27 residents on the evening shift, required 3 total staff. -05/12/23 had 1.6 CNAs for 27 residents on the day shift, required 3 CNAs. -05/12/23 had 2.2 total staff for 27 residents on the evening shift, required 3 total staff. -05/13/23 had 1.7 CNAs for 27 residents on the day shift, required 3 CNAs. -05/13/23 had 2 total staff for 27 residents on the evening shift, required 3 total staff. -05/13/23 had 1 total staff for 27 residents on the overnight shift, required 2 total staff. -05/14/23 had 0.5 CNAs for 27 residents on the day shift, required 3 CNAs. -05/14/23 had 2.1 total staff for 27 residents on the day shift, required 3 total staff. -05/15/23 had 0.8 CNAs for 28 residents on the day shift, required 3 CNAs. -05/15/23 had 2 total staff for 28 residents on the evening shift, required 3 total staff. -05/16/23 had 0.5 CNAs for 28 residents on the day shift, required 3 CNAs. -05/16/23 had 2.1 total staff for 28 residents on the evening shift, required 3 total staff. -05/17/23 had 0.8 CNAs for 28 residents on the day shift, required 3 CNAs. -05/17/23 had 2 total staff for 28 residents on the evening shift, required 3 total staff. -05/18/23 had 0.4 CNAs for 28 residents on the day shift, required 3 CNAs. -05/18/23 had 2.1 total staff for 28 residents on the evening shift, required 3 total staff. -05/18/23 had 1.2 total staff for 28 residents on the overnight shift, required 2 total staff. -05/19/23 had 2.1 CNAs for 28 residents on the day shift, required 3 CNAs. -05/20/23 had 2.2 CNAs for 28 residents on the day shift, required 3 CNAs. -05/20/23 had 2.8 total staff for 28 residents on the evening shift, required 3 total staff. On 6/01/23 at 10:30 AM the surveyor interviewed the DON and Assistant Director of Nursing (ADON). The ADON stated the LNHA did not want 2 nurses to be working together on the day shift because there is not enough work for them. They explained that LPN #1 is an in house nurse and lives here at the facility. She was offered a room but prefers to sleep in a reclining chair in the dayroom. She showers at the facility. There are multiple times when LPN #1 will do medication pass, rest for an hour, and then go back on the floor to resume nursing duties. The DON stated LPN #1 is frequently working 7 AM- 3 PM, 3 PM - 11 PM and 11 PM - 7 AM shifts. The DON stated that LPN #1 is the on duty nurse almost all the time and that this was not safe for the residents because the nurse is not resting enough. She further stated good CNAs have left because of the number of residents each CNA is responsible for. They cannot handle the work. On 6/05/23 at 11:17 AM the surveyor interviewed the LNHA regarding the failure to meet the State minimum staffing requirements. The LNHA stated she has used overtime to meet staffing for CNAs and LPNs. The LNHA stated she does not use temporary staff because that goes against you financially. She stated she has utilized on-line employment agencies. She stated she has daily contact with job applicants. The new employees will come on board and work for a while and resign. New employees don't want to work here because we are small so there is no place to hide out in the open. [they must] work all day long so they don't want to work here. If staffing is too high, it goes against you. [I] know the requirement, [there] would have to be 2 CNAs on 11-7 but this facility doesn't need it. She further stated perfect staffing for 29 census would be 2 nurses and 3 CNAs on day shift, 1 nurse and 2 CNAs each on evening and night shifts. On 6/05/23 at 2:20 PM the surveyor requested from the LNHA policies related to staffing. None was provided to the surveyor. As evidenced by observation, interview, and review of pertinent records, it was clear that facility administration was aware of the dangerously low nursing and CNA staffing on all shifts. Facility administration was aware of the frequency of multiple consecutive shifts worked by LPN #1 with 1 CNA. Facility administration was aware of CNAs working on a unit without nursing supervision and without performance appraisals and competencies. Facility administration failed to complete performance appraisals and competencies on licensed nurses. These actions placed all 29 residents in the facility at risk for serious harm, impairment, or death from lack of adequate supervision. The administration was aware of this practice and did not implement procedures to correct it. On 6/5/23 at 2:26 PM, the facility LNHA was notified of the IJ. On 6/6/23 at 12:45 PM, the surveyors were provided the RP. After review it was rejected based on insufficient evidence which was needed to remove the immediacy. The surveyor discussed this with the LNHA. On 6/7/23 at 10:00 AM, the surveyor requested the RP, which was not provided. The LNHA explained that she is still working on the RP. On 6/07/23 at 12:40 PM, the surveyor requested the RP, which was not provided again. The LNHA explained that she is not sure if the RP will be ready today. On 6/08/23 at 10:45 AM, the surveyors reviewed the RP sent by the facility and after review it was rejected based on insufficient evidence which was needed to remove the immediacy. The surveyor discussed this with the LNHA. After the facility revised the RP, it was accepted. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview and review of records. NJAC 8:39-5.1(a) NJAC 8:39-27.1(a)

Complaint #s NJ00155172, NJ00161276, NJ00160806, NJ00159306 Refer to F689, F756, F760, F836 Based on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure a.) staffing levels outlined in the Facility Assessment Tool were consistently met to address the population census and needs of their residents; b.) minimum State staffing requirements were met for 17 weeks of 17 weeks reviewed during which time the facility continued to admit residents; c.) safe medication administration to residents resulting in significant medication errors; d.) Consultant Pharmacist (CP) monthly medication review reports were acted upon by the Director of Nursing (DON) and the Physician in a timely manner; e.) adequate supervision and competent staff when Licensed Practical Nurse #1 (LPN #1) would sleep during excessive continuous hours at work, leaving no nurse to supervise the Certified Nursing Assistant (CNA) and no nurse to supervise the 29 residents while LPN #1 slept. The failure of the LNHA to ensure the facility operated safely by following staffing benchmarks outlined in the Facility Assessment Tool and following State minimum staffing requirements while continuing to admit new residents placed all residents at risk for serious harm, impairment, or death, which resulted in a citation for F836L. Staff interviews revealed short staffing was typical, often consisting of 1 nurse and 1 CNA. This resulted in citations for F689L and F836L. Multiple significant medication administration errors were identified, which resulted in a citation for F760K. Failure to respond to the CP's monthly medication review reports resulted in a citation for F756K. Additionally, the LNHA failed to actively engage the Medical Director regarding ongoing concerns expressed during the survey. The LNHA was notified of the initial Immediate Jeopardy (IJ) on 6/1/23 at 4:28 PM for F756K and F760K. The LNHA was notified of subsequent IJs on 6/5/23 at 2:26 PM for F836L, F689L, and F835L. An acceptable written Removal Plan (RP) was received on 6/8/23. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview, and review of records. The evidence was as follows: 1. On 5/24/23 at 9:30 AM, the surveyor observed one LPN and one CNA working on the nursing unit. The surveyor interviewed the Social Services Director (SSD), who stated the census was 29, and there was one LPN (LPN #1) and one CNA (CNA #1) working the day shift. The SSD stated LPN #1 and CNA #1 also worked the previous 11 PM to 7 AM shift. The SSD stated the facility was actively recruiting candidates; however, they are hired and just don't show up for work. The surveyor reviewed the written nursing schedule for the week beginning 5/23/23. LPN #1 was scheduled as the only nurse on 5/23 from 11:15 PM to 7 AM; on 5/24 from 7 AM to 3:45 PM and 11 PM to 7 AM; on 5/25 from 7 AM to 3:30 PM and 10:45 PM to 8:15 AM. CNA #1 was scheduled as the only CNA on 5/23 from 11 PM to 7 AM, on 5/24 from 11 PM to 9:30 AM, and on 5/25 from 8 PM to 8 AM. A further review of staffing for the period of 5/1/23 -5/31/23 revealed LPN #1 worked daily with no days off for 31 days. LPN #1 worked five times for 24 consecutive hours, one time for 26.5 consecutive hours, and thirteen times for 16 consecutive hours. There were no CNAs on duty at the facility for the following times: - 5/2/23: 11 PM to 7 AM - 5/3/23: 7:00 AM to 10:30 AM; 11 PM to 7 AM - 5/9/23: 7 AM - 10:00 AM - 5/10/23: 7 AM - 10:00 AM - 5/13/23: 11 PM - 7 AM - 5/16/23: 8:30 AM - 10:00 AM - 5/17/23: 7 AM - 2 PM - 5/18/23: 7 AM - 2 PM; 11 PM- 7 AM - 5/22/23: 7 AM - 10 AM There were no nurses in the building on 5/4/23 from 3 PM to 6 PM. On 5/23/23, there was no Registered Nurse (RN) on duty during any of the three shifts. On 5/26/23, the LNHA provided the surveyor with the Facility Assessment Tool, updated on 5/1/23. Part 2, Example 2 described the general staffing plan to ensure enough staff is on hand to meet the needs of residents at any given time. The breakdown was as follows: Director of Nursing (DON) - one full-time day. An RN or LPN Charge Nurse for each shift (for 1-18 residents, the DON may be a Charge Nurse). One licensed nurse for every 36 residents on day and evening shifts. One licensed nurse for every 18 residents on the night shift. Direct Care Staff required was listed as 1 direct care staff person for 36 residents on day, evening, and night shifts. 2. On 6/2/23, staffing was obtained from the LNHA for a total of 17 weeks in three segments: 8/28/22 - 11/5/22 and 1/01/23 - 2/04/23 (periods when complaints were lodged for the shortage of staffing) and 5/07/23 - 5/20/23 (two weeks prior to the standard recertification survey). A review of the documentation revealed the following. For the 10 weeks of staffing from 8/28/22 to 11/05/22, the facility was deficient in CNA staffing for residents on 70 of 70 day shifts, deficient in total staff for residents on 35 of 70 evening shifts, deficient in CNAs to total staff on two of 70 evening shifts, and deficient in total staff for residents on 18 of 70 overnight shifts. For the five weeks of staffing from 1/01/23 to 2/04/23, the facility was deficient in CNA staffing for residents on 34 of 35 day shifts, deficient in total staff for residents on eight of 35 evening shifts, deficient in CNAs to total staff on six of 35 evening shifts, and deficient in total staff for residents on six of 35 overnight shifts. For the two weeks of staffing prior to the survey from 5/07/23 to 5/20/23, the facility was deficient in CNA staffing for residents on 14 of 14-day shifts, deficient in total staff for residents on 11 of 14 evening shifts, deficient in CNAs to total staff on one of 14 evening shifts, and deficient in total staff for residents on two of 14 overnight shifts. 3. Significant medication errors occurred regarding the documentation and administration of critical medications, including anticoagulants and insulin medications to prevent serious adverse outcomes were identified for Resident #13, #19, and #20, who required blood sugar monitoring and were dependent on insulin; Resident #13, 17, 20, 25 and 230 who had physician orders for anticoagulant medication to prevent blood clotting; and Resident #19 who had a physicians order for an oral hypoglycemic agent (medication to lower blood sugar). The facility nurse failed to ensure that Resident #18 received medication that was first validated by the physician and the pharmacy, reviewed for allergies, and entered into the electronic Medication Administration Record (eMAR) to prevent serious adverse outcomes, including significant allergic reactions. The facility nurse's failure to monitor and document blood sugars and administer insulin and oral hypoglycemic agents when it was indicated in accordance with a physician's order was likely to result in hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), which would require immediate emergency intervention if the resident became symptomatic. The facility nurse's failure to administer and document an anticoagulant in accordance with a physician's order to prevent blood clots increased the risk of heart attack, pulmonary embolism (a blood clot that enters the lung), anoxic stroke (a blood clot that stops oxygen to the brain), or other blood clots throughout the body. Residents #13, 17, 25, 20, 230 were identified as having anticoagulant under and overdosing. Resident #25 received double dosing of an anticoagulant medication for 5 days, increasing the bleeding risk. This resulted in an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 6/1/23 which began on 3/7/23 (the start date on which the Consultant Pharmacist alerted the facility of concerns on documentation of medications on the eMAR) and continued until 6/8/23 when the facility implemented their written removal plan. The facility's Licensed Nursing Home Administrator (LNHA) was notified of the IJ on 6/1/23 at 4:28 PM. An acceptable written Removal Plan (RP) was received on 6/8/23. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview, and review of records. This deficient practice was identified for 7 of 17 residents reviewed for medication management (Resident #13, #17, # 18, #19, #20, # 25, and #230). 4. Consultant Pharmacist (CP) recommendations dated on 3/7/23 were not acted upon in a timely manner. The recommendations regarded the documentation and administration of critical medications, including anticoagulants and insulin medications, to prevent serious adverse outcomes. Residents #13, #19, and #20 required blood sugar monitoring and were dependent on insulin. Residents #17 and #230 required anticoagulant medication to prevent blood clotting. The failure to act upon the CP recommendations in a timely manner to ensure all residents were accurately receiving the necessary medications in the appropriate timeframe in accordance with their physician's order to prevent an adverse outcome placed all residents who receive critical medications at risk for a serious outcome. The failure to monitor and document blood sugars and administer insulin when it was indicated in accordance with physician orders is likely to result in hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), both of which require immediate emergency intervention. The failure to administer and document anticoagulant medication in accordance with a physician's order to prevent blood clots is likely to lead to heart attack, pulmonary embolism (a blood clot that enters the lung), anoxic stroke (a blood clot that stops oxygen to the brain), or other blood clots throughout the body. 5. The surveyor interviewed LPN #1 on 6/1/23 at 10:59 AM. She stated her regular shift was 11 PM - 7 AM. LPN #1 stated the 7 AM - 3 PM nurse resigned last month. The 3 PM - 11 PM nurse (LPN #2) works 2 to 3 times a week. LPN #1 stated she frequently works multiple shifts in a day, including all 3 shifts if no other nurse is scheduled. LPN #1 stated that when she works 24 hours consecutively, she will get a 1 - 2 hour break to sleep. There is one CNA working with her and no covering nurse when she takes a break. On 6/01/23 at 10:30 AM, the surveyor interviewed the DON and Assistant Director of Nursing (ADON). The ADON stated the LNHA did not want 2 nurses to be working together on the day shift because there is not enough work for them. She further stated good CNAs have left because of the number of residents each CNA is responsible for. They cannot handle the work. They explained that LPN #1 is an in-house nurse and lives here at the facility. She was offered a room but prefers to sleep in a reclining chair in the dayroom. She showers at the facility. There are multiple times when LPN #1 will do a medication pass, rest for an hour, and then return to the floor to resume nursing duties. The DON stated LPN #1 frequently works 7 AM- 3 PM, 3 PM - 11 PM, and 11 PM - 7 AM shifts. The DON stated that LPN #1 is the on duty nurse almost all the time and that this was not safe for the residents because the nurse is not resting enough. On 6/05/23 at 11:30 AM, the LNHA provided the surveyor with a document titled In-House Universal Staff Nurse which was signed by LPN #1 on 10/14/22. The section titled In-House Residency indicated the nurse will typically work two 8-hour shifts and are [sic] permitted to leave or sleep on the premises. The LNHA explained LPN #1 is like a Resident in a hospital. LPN #1 can sleep in the facility and be on call for when she is needed by the CNA. On 6/6/23 at 12:45 PM, the surveyors were provided the RP. After review, it was rejected based on insufficient evidence, which was needed to remove the immediacy. The surveyor discussed this with the LNHA. On 6/7/23 at 10:00 AM, the surveyor requested the RP, which was not provided. The LNHA explained that she is still working on the RP. On 6/07/23 at 12:40 PM, the surveyor requested the RP, which was not provided again. The LNHA explained that she is unsure if the RP will be ready today. On 6/08/23 at 10:45 AM, the surveyors reviewed the RP sent by the facility, and after review, it was rejected based on insufficient evidence, which was needed to remove the immediacy. The surveyor discussed this with the LNHA. After the facility revised the RP, it was accepted. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview and review of records. NJAC 8:39-4.1(a)11; NJAC 8:39-25.2(a)(b); NJAC 8:39-27.1(a); NJAC 8:39-29.2(d); NJAC 8:39-29.3(a)1. 3. 6.

Complaint #s NJ00155172, NJ00161276, NJ00160806, NJ00159306 Refer to F760K; F835L; F836L Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure 29 residents were adequately supervised when Licensed Practical Nurse (LPN) #1 worked 24 hours straight, six times in May 2023 with one Certified Nursing Assistant (CNA) #1 on the assignment during designated shifts. The failure to have adequate staff led to a lack of supervision for residents, which increased the risk of improper care, resident neglect, accidents such as falls, entrapments or elopements, and/or medication administration errors or omissions. Serious injury or death may have occurred due to staff inability to respond to an emergent situation in a timely manner. This resulted in an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 6/5/23, and it continued until 6/8/23, when the facility implemented their written removal plan. The facility's Licensed Nursing Home Administrator (LNHA) was notified of the IJ on 6/5/23 at 2:26 PM. An acceptable written Removal Plan (RP) was received on 6/8/23. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview, and review of records. The evidence is as follows: On 5/24/23 at 9:30 AM, the surveyor observed one LPN and one CNA working in the nursing unit. The surveyor interviewed the Social Services Director (SSD), who stated the census was 29, and there was one LPN (LPN #1) and one CNA (CNA #1) working the day shift. The SSD stated LPN #1 and CNA #1 also worked the previous 11 PM to 7 AM shift. The SSD stated the facility was actively recruiting candidates; however, they are hired and just don't show up for work. The surveyor reviewed the written nursing schedule for the week beginning 4/23/23. LPN #1 was scheduled as the only nurse on 5/23 from 11:15 PM to 7 AM; on 5/24 from 7 AM to 3:45 PM and 11 PM to 7 AM; on 5/25 from 7 AM to 3:30 PM and 10:45 PM to 8:15 AM. CNA #1 was scheduled as the only CNA on 5/23 from 11 PM to 7 AM, on 5/24 from 11 PM to 9:30 AM, and 5/25 from 8 PM to 8 AM. On 6/2/23, staffing was obtained from the LNHA for a total of 17 weeks in three segments: 8/28/22 - 11/5/22 and 1/01/23 - 2/04/23 (periods when complaints were lodged for the shortage of staffing) and 5/07/23 - 5/20/23 (two weeks prior to the standard recertification survey). A review of the documentation revealed the following. For the 10 weeks of staffing from 8/28/22 to 11/05/22, the facility was deficient in CNA staffing for residents on 70 of 70 day shifts, deficient in total staff for residents on 35 of 70 evening shifts, deficient in CNAs to total staff on two of 70 evening shifts, and deficient in total staff for residents on 18 of 70 overnight shifts. For the five weeks of staffing from 1/01/23 to 2/04/23, the facility was deficient in CNA staffing for residents on 34 of 35 day shifts, deficient in total staff for residents on eight of 35 evening shifts, deficient in CNAs to total staff on six of 35 evening shifts, and deficient in total staff for residents on six of 35 overnight shifts. For the two weeks of staffing prior to the survey from 5/07/23 to 5/20/23, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts, deficient in total staff for residents on 11 of 14 evening shifts, deficient in CNAs to total staff on one of 14 evening shifts, and deficient in total staff for residents on two of 14 overnight shifts. A further review of staffing for the period of 5/1/23 -5/31/23 revealed LPN #1 worked daily with no days off for 31 days. LPN #1 worked five times for 24 consecutive hours, one time for 26.5 consecutive hours, and thirteen times for 16 consecutive hours. There were no CNAs on duty at the facility for the following times: - 5/2/23: 11 PM to 7 AM - 5/3/23: 7:00 AM to 10:30 AM; 11 PM to 7 AM - 5/9/23: 7 AM - 10:00 AM - 5/10/23: 7 AM - 10:00 AM - 5/13/23: 11 PM - 7 AM - 5/16/23: 8:30 AM - 10:00 AM - 5/17/23: 7 AM - 2 PM - 5/18/23: 7 AM - 2 PM; 11 PM- 7 AM - 5/22/23: 7 AM - 10 AM There were no nurses in the building on 5/4/23 from 3 PM to 6 PM. On 5/23/23, there was no Registered Nurse (RN) on duty during any of the three shifts. On 5/26/23, the LNHA provided the surveyor with the Facility Assessment Tool, updated 5/1/23. Part 2, Example 2 described the general staffing plan to ensure enough staff is on hand to meet the needs of residents at any given time. The breakdown was as follows: Director of Nursing (DON) - one full time day. An RN or LPN Charge Nurse for each shift (for 1-18 residents, the DON may be a Charge Nurse). One licensed nurse for each 36 residents on day and evening shifts. One licensed nurse for each 18 residents on the night shift. Direct Care Staff required was listed as 1 direct care staff person for 36 residents on day, evening, and night shifts. The surveyor interviewed CNA #1 on 6/1/23 at 10:06 AM. CNA #1 stated she had worked at the facility for one year and 4 months and is the only CNA who works the 11 PM - 7 AM shift. She stated she has only worked with LPN #1 on the night shift. CNA #1 stated LPN #1 may have been off for one or two days during the time CNA #1 has worked. There was no coverage of nurses at that time. She did not remember the dates. CNA #1 stated it was very difficult to take care of all the residents by herself. She stated LPN #1 appeared tired all the time and has observed her sleeping while on duty. CNA #1 stated she would wake LPN #1 if the nurse was needed. CNA #1 stated she has spoken to the LNHA about the shortage of staff on the night shift. CNA #1 has told the LNHA that LPN #1 is exhausted. The surveyor interviewed CNA #2 on 6/1/23 at 9:55 AM. She stated she has worked at the facility since 11/2022 and works only on the day shift. CNA #2 stated there are days when she is the only CNA working. She said the facility does not utilize temporary agency staff. She stated it is very difficult to provide care to all the residents, especially when there are call outs. The surveyor interviewed CNA #8 on 6/1/23 at 10:26 AM. The CNA stated he has worked at the facility on Friday, Saturday, and Sunday for the past 2 1/2 months. He stated it is very difficult to care for all the residents by himself. He stated he takes no breaks and is unable to get assistance from the nurse working with him because the nurse is also very busy. The surveyor interviewed the Activity Director (AD) on 6/1/23 at 10:30 AM. The AD was employed at the facility for thirteen years. She stated staffing has never been as short as it is at present, especially since the COVID-19 pandemic. The AD stated, sometimes medications are given a little late. Sometimes resident care is a little late. There are times when only 1 CNA works on a shift, especially if there is a call out. The nurse helps with resident care. There is a lot of sacrifice here by the staff. The surveyor interviewed LPN #1 on 6/1/23 at 10:59 AM. She stated her regular shift was 11 PM - 7 AM. LPN #1 stated the 7 AM - 3 PM nurse resigned last month. The 3 PM - 11 PM nurse (LPN #2) works 2 to 3 times a week. LPN #1 stated she frequently works multiple shifts in a day, including all 3 shifts if no other nurse is scheduled. LPN #1 stated that when she works 24 hours consecutively, she will get a 1 - 2 hour break to sleep. There is one CNA working with her and no covering nurse when she takes a break. On 6/01/23 at 10:30 AM, the surveyor interviewed the DON and Assistant Director of Nursing (ADON). The ADON stated the LNHA did not want 2 nurses to be working together on the day shift because there is not enough work for them. She further stated good CNAs have left because of the number of residents each CNA is responsible for. They cannot handle the work. They explained that LPN #1 is an in house nurse and lives here at the facility. She was offered a room but prefers to sleep in a reclining chair in the dayroom. She showers at the facility. There are multiple times when LPN #1 will do medication pass, rest for an hour, and then go back on the floor to resume nursing duties. The DON stated LPN #1 frequently works 7 AM- 3 PM, 3 PM - 11 PM, and 11 PM - 7 AM shifts. The DON stated that LPN #1 is the on duty nurse almost all the time and that this was not safe for the residents because the nurse is not resting enough. On 6/05/23 at 11:17 AM, the surveyor interviewed the LNHA regarding the failure to meet staffing requirements outlined in the Facility Assessment Tool and the State minimum staffing requirements. The LNHA stated overtime has been the answer for the ability to meet staffing for CNAs and LPNs. The LNHA stated she does not allow staff to work 3 shifts in a row. The LNHA stated she does not use temporary staff because that goes against you financially. She stated she has utilized on-line employment agencies. She stated she has daily contact with job applicants. The new employees will come on board and work for a while and resign. New employees don't want to work here because we are small, so there is no place to hide out in the open. [they must] work all day long, so they don't want to work here. If staffing is too high, it goes against you. [I] know the requirement, [there] would have to be 2 CNAs on 11-7, but this facility doesn't need it. She further stated perfect staffing for 29 census would be 2 nurses and 3 CNAs on day shift, 1 nurse and 2 CNAs each on evening and night shifts. On 6/05/23 at 11:30 AM, the LNHA provided the surveyor with a document titled In-House Universal Staff Nurse which was signed by LPN #1 on 10/14/22. The section titled In-House Residency indicated the nurse will typically work two 8-hour shifts and are [sic] permitted to leave or sleep on the premises. The LNHA explained LPN #1 is like a Resident in a hospital. LPN #1 can sleep in the facility and be on call when she is needed by the CNA. On 6/05/23 at 12:12 PM, the surveyor requested from the LNHA annual performance appraisals and competencies for all current nurses and CNAs on the payroll. The LNHA referred the surveyor to the DON. The DON stated she could not locate them and would contact the previous DON to see if they are filed at the facility. On 6/05/23 at 3:30 PM, the surveyor was provided with all of LPN #1's competencies. They were as follows: Enteral Nutrition Feeding, 10/29/22; Personal Protective Equipment (PPE) Competency Validation, 11/13/22; Hand Washing, 11/13/22; Binax Now Competency Record (nasal swab for COVID-19 testing), 9/10/22. No further competencies or performance appraisals used for the evaluation of knowledge and skill set for nurses and CNAs were provided to the surveyor. On 6/05/23 at 2:20 PM, the surveyor requested the LNHA policies related to staffing. None was provided to the surveyor. As evidenced by observation, interview, and review of pertinent records, it was clear that facility administration was aware of the dangerously low nursing and CNA staffing on all shifts. Facility administration was aware of the frequency of multiple consecutive shifts worked by LPN #1 with 1 CNA. Facility administration was aware of CNAs working on a unit without nursing supervision and without performance appraisals and competencies. Facility administration failed to complete performance appraisals and competencies on licensed nurses. These actions placed all 29 residents in the facility at risk for serious harm, impairment, or death from lack of adequate supervision. The administration was aware of this practice and did not implement procedures to correct it. On 6/5/23 at 2:26 PM, the facility LNHA was notified of the IJ. On 6/6/23 at 12:45 PM, the surveyors were provided the RP. After review, it was rejected based on insufficient evidence, which was needed to remove the immediacy. The surveyor discussed this with the LNHA. On 6/7/23 at 10:00 AM, the surveyor requested the RP, which was not provided. The LNHA explained that she is still working on the RP. On 6/07/23 at 12:40 PM, the surveyor requested the RP, which was not provided again. The LNHA explained that she is unsure if the RP will be ready today. On 6/08/23 at 10:45 AM, the surveyors reviewed the RP sent by the facility, and after review, it was rejected based on insufficient evidence, which was needed to remove the immediacy. The surveyor discussed this with the LNHA. After the facility revised the RP, it was accepted. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview, and review of records. NJAC 8:39-27.1(a)

Refer to 760K Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) recommendations dated 3/7/23 were acted upon in a timely manner regarding the documentation and administration of critical medications, including anticoagulants and insulin medications to prevent serious adverse outcomes for Resident #13, #19 and #20 who required blood sugar monitoring and were dependent on insulin, and Resident #17 and #230 who had physician orders for an anticoagulant to prevent blood clotting. The failure to act upon the CP recommendations in a timely manner to ensure all residents were accurately receiving the necessary medications in the appropriate timeframe in accordance with their physician's orders to prevent an adverse outcome placed all residents who received critical medications at risk for a serious outcome. The failure to monitor and document blood sugars and administer insulin when indicated per the physician's order is likely to result in hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), which requires immediate emergency intervention if symptomatic. The failure to administer and document an anticoagulant in accordance with a physician's order to prevent blood clots is likely to lead to a heart attack, pulmonary embolism (a blood clot that enters the lung), anoxic stroke (a blood clot that stops oxygen to the brain), or other blood clots throughout the body. This resulted in an Immediate Jeopardy (IJ) situation that began on 3/7/23 when the CP made their recommendations. The facility's Licensed Nursing Home Administrator (LNHA) was notified of the IJ on 6/1/23 at 4:28 PM. The IJ continued until 6/8/23, when the facility implemented its written removal plan. An acceptable written Removal Plan (RP) was received on 6/8/23. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview, and review of records. This deficient practice was identified for 5 of 17 residents reviewed for medication management (Resident #13, #17, #19, #20, and #230). The evidence was as follows: 1. On 5/24/23 at 10:40 AM, the surveyor observed Resident #19 in a wheelchair in the dining area with their eyes closed. The surveyor attempted to interview the resident, but the resident could not answer the surveyor's inquiry. According to the Admission Record (AR), an admission summary, Resident #19 was admitted to the facility with diagnoses that included but were not limited to type 2 diabetes mellitus (a chronic disease where the body doesn't produce enough insulin, thereby affecting blood sugar levels) and Alzheimer's disease (impaired cognition). A review of the physician Order Summary Report (OSR) for May 2023 revealed the following Physician's Order (PO) for Novolog (fast-acting insulin) injection solution 100 unit/ml (Insulin Aspart), dated 3/1/23. The orders specified injecting insulin subcutaneously (under the skin) before meals and at bedtime using the sliding scale for insulin coverage: if the fasting blood sugar is 70-130, administer 0 units of insulin; if the fasting blood sugar is 131-180, administer 2 units of insulin; if the fasting blood sugar was181-240, administer 4 units of insulin; if the fasting blood sugar is 241-300, administer 6 units of insulin; if the fasting blood sugar is 301-350, administer 8 units of insulin; if the fasting blood sugar is 351-400, administer 10 units of insulin; if the fasting blood sugar is above 400, give 10 units, then call the physician (MD) for an order. A review of the March 2023 Electronic Medication Administration Reports (eMAR) did not show documentation of the administration of critical medication Novolog insulin for 45 of 120 doses due. A review of April 2023 eMAR did not show documentation of the administration of critical medication Novolog insulin for 31 of 120 doses due. A review of May 2023 eMAR did not show documentation of the administration of critical medication Novolog insulin for 65 of 120 doses due. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 99, which required no Humalog insulin, to 231, requiring 4 units of Humalog to be administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 111, which required no Humalog insulin, to 276, requiring 6 units of Humalog to be administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 100, which required no Humalog insulin, to 192, requiring 4 units of Humalog to be administered. There was no documentation that blood sugar was taken on each of the omitted insulin doses and no documentation of hospitalization , hypoglycemia, or hyperglycemia. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. A review of the March, April, and May 2023 CP recommendations revealed no specific CP recommendations addressing the omissions in the resident's eMAR. The CP Consultant Evaluation form dated 5/4/23 noted an HBA1C of 6.1 results from 4/4/23. 34421 2. On 5/31/23 at 11:40 AM, the surveyor observed Resident #20 in the resident's room in a chair. The resident's eyes were closed. The surveyor attempted to interview the resident, but the resident was unable to answer the surveyor's inquiry. According to the AR, Resident #20 was admitted to the facility with diagnoses that included but were not limited to type 2 diabetes mellitus, atrial fibrillation (AFib) (an irregular, rapid heart rate that typically requires anticoagulants to prevent blood clotting), and psychotic disorder. A review of the OSR for May 2023 revealed the following POs for Humalog (fast-acting insulin) injection solution 100 unit/ml (Insulin Lispro) dated 3/1/23. The order specified to inject the insulin subcutaneously under the skin as per the sliding scale: if the fasting blood sugar is 0-150, administer 0 units of insulin; if the fasting blood sugar is 151-180, administer 2 units of insulin; if the fasting blood sugar is 181-240, administer 4 units of insulin; if the fasting blood sugar is 241-300, administer 6 units of insulin; if the fasting blood sugar is 301-350, administer 8 units of insulin; if the fasting blood sugar is 351-400, administer 10 units of insulin; An additional PO dated 3/1/23 administered Lantus (long-acting insulin) subcutaneous solution 100 unit/ml (Insulin Glargine). The order specified injecting 15 units subcutaneously at bedtime for type 2 diabetes. In addition, there was a physician's order for Xarelto (an anticoagulant) dated 3/1/23. The order specified administering Xarelto 15 milligrams (mg), one tablet by mouth in the evening for AFib. A review of March 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 37 of 120 doses due, Lantus for 12 of 31 doses due, and Xarelto for 8 of 31 doses due. A review of April 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 25 of 120 doses due, Lantus for 5 of 30 doses due, and Xarelto for 4 of 30 doses due. A review of May 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 49 of 120 doses due, Lantus for 15 of 30 doses due, and Xarelto for 13 of 30 doses due. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 58, which required no Humalog insulin, to 389, requiring 10 units of Humalog to be administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 39, which required no Humalog insulin, to 400, requiring 10 units of Humalog to be administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 74, which required no Humalog insulin, to 368, requiring 10 units of Humalog to be administered. There was no documentation revealing a blood sugar taken on each of the omitted insulin doses and no documentation of hospitalization , hypoglycemia, or hyperglycemia. There was no documented evidence that the resident had a hospitalization . A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. A review of the March, April, and May 2023 CP recommendations revealed no specific CP recommendations addressing the omissions in the resident's eMAR. The CP Consultant Evaluation form dated 5/4/23 noted an HBA1C of 7.1 results from 4/4/23. 3. On 6/1/23 at 10:45 AM, the surveyor observed Resident #230 in a chair in the resident's room. The surveyor attempted to interview the resident, but the resident was unable to answer. According to the AR, Resident #230 was admitted to the facility with diagnoses that included but were not limited to AFib and dementia. A review of the OSR for May 2023 revealed the following POs for Eliquis (an anticoagulant) 2.5 mg, given 2.5mg by mouth two times a day for Afib with a start date of 5/13/23. A review of May 2023 eMAR did not show documentation of the administration of the critical medications of Eliquis for 13 of 36 doses due. There was no documented evidence of hospitalization . A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. A review of the March, April, and May 2023 CP recommendations revealed no specific CP recommendations addressing the omissions in the resident's eMAR. 34033 4. On 6/7/23 at 11:23 AM, the surveyor observed Resident #13 in bed. The resident was unable to answer any questions. The surveyor reviewed the electronic medical record for Resident #13. A review of the AR revealed that the resident had diagnoses that included but were not limited to dementia, AFib, and type 2 diabetes mellitus. A review of the May 2023 OSR revealed the following POs: - start date of 3/1/23 Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth two times a day for A Fib. - start date of 3/1/23 HumaLog injection solution (Insulin Lispro), 100 Unit/ML, inject as per sliding scale: if 0-150=0; 151-200=2; 201-250=3; 251-300=4; 301-350=5;351-400=6, if above 400, give 8 units then recheck after 1 hour, subcutaneously (SC) before meals and at bedtime for DM2. - start date of 3/1/23 Lantus Subcutaneous Solution 100 Units/ML (Insulin Glargine), inject 16 units SC at bedtime for DM2. A review of the March 2023 eMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 10 out of 62 omitted doses. - Humalog had a total of 44 out of 124 omitted doses. - Lantus had a total of 13 out of 31 omitted doses. A review of the April 2023 eMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 6 out of 60 omitted doses. - Humalog had a total of 27 out of 120 omitted doses. - Lantus had a total of 6 out of 30 omitted doses. A review of the May 2023 eMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 26 out of 62 omitted doses. - Humalog had a total of 65 out of 124 omitted doses. - Lantus had a total of 18 out of 31 omitted doses. There was no documentation revealing a blood sugar taken on each of the omitted insulin doses and no documentation of hospitalization , hypoglycemia, or hyperglycemia. There was no documentation revealing any blood clotting concerns identified nor any documentation of hospitalization for this resident. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 98, which required no Humalog insulin, to 299, requiring 4 units of Humalog that were administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 80, which required no Humalog insulin, to 324, requiring 5 units of Humalog that were administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 103, which required no Humalog insulin, to 314, requiring 5 units of Humalog that were administered. A review of the March, April, and May 2023 CP recommendations revealed no specific CP recommendations addressing the omissions in the resident's eMAR. The CP Consultant Evaluation form dated 5/4/23 noted an HBA1C of 8.1 results from 4/4/23 was noted. There was no specific recommendation made for the facility or the physician. 5. On 6/7/23 at 11:39 AM, the surveyor observed Resident #17 in a wheelchair at the back of the dining/day room. The resident ended a phone call using the facility telephone. The resident stated that they had called their physician because they wanted to check on something. The resident also said that they received their medications because they see LPN#1 all the time and knew that they were supposed to take their antibiotic, Augmentin, with food. The resident was unable to speak to all medications that were administered or what times they were administered. The surveyor reviewed the electronic medical record for Resident #17. A review of the AR revealed that the resident had diagnoses that included but were not limited to dementia and AFib. A review of the May 2023 OSR revealed a PO with a start date of 3/1/23 for Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth every 12 hours for AFib. - start date of 3/1/23 Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth two times a day for A Fib. A review of the March 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 17 out of 62 omitted doses. A review of the April 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 10 out of 60 omitted doses. A review of the May 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 29 out of 62 omitted doses. There was no documentation revealing any blood clotting concerns identified nor any documentation of hospitalization for this resident. A review of the Progress Notes revealed no follow-up with the physician regarding medication omissions in the eMARs. A review of the CP recommendations and monthly evaluations for March, April, and May 2023 revealed no specific CP recommendation addressing omissions from the resident's eMAR. A review of the CP monthly report, dated 3/7/23, revealed that the pharmacist indicated a general note that blanks were noted in the eMAR and issues discussed with the administrator. No specific resident was pointed out on the monthly report to show which resident's charts had omissions. There was no indication that the facility reviewed this recommendation, and no signature or follow-up note was written. A review of the CP monthly report, dated 4/5/23, revealed that the pharmacist indicated frequent charting omissions noted in March, with some improvement in April, and that pharmacy recommendations still need to be addressed from March. No specific resident was pointed out on the monthly report to indicate which resident's charts had omissions and the seriousness of omitting the medications prescribed. There was no indication that the facility reviewed this recommendation, and no signature or follow-up note was written. A review of the CP monthly report, dated 5/5/23, revealed that the pharmacist indicated that there were frequent charting omissions from the resident's charts and the report specified e.g., 0600 4/3, 4/4, 4/6, 4/7, 4/17, 4/18, 4/19, 4/21, 4/25, 5/1, 5/3; 0900 4/1, 4/6, 4/16, 4/19, 4/24, 5/1, 5/3; 1400 4/1, 4/6, 4/10, 4/16, 4/19, 4/24; 2100 4/5, 4/7, 4/16, 4/21, 4/27, 5/2. There was no specific resident note on the monthly report to indicate which resident this note referred to and which charts had medication omissions. There was no indication that the facility reviewed this recommendation, and no signature or follow-up note was written. On 6/1/23 at 11:00 AM, the surveyor interviewed LPN #1 regarding the omitted medication administration in the eMARs, and LPN #1 stated that she was signing the medication she administers but could not speak for other nurses if they were signing for them or not. LPN #1 added that she did not have time to check those signatures. On 6/1/23 at 3:08 PM, the surveyor attempted to contact the CP via telephone. On 6/1/23 at 4:13 PM, the surveyors interviewed the Director of Nursing (DON) and the LNHA, who stated that LPN #1 was not fast enough to complete her work and was being pulled to do other tasks. On 6/1/23 at 4:28 PM, the facility LNHA was notified of the IJ. On 6/2/23 at 10:09 AM, the surveyor interviewed the CP supervisor, who stated that the pharmacy recommendation reports get sent to the DON, and it is up to the facility's nursing staff to respond to the report. The CP supervisor stated that days and times for frequent charting omissions might not specify the resident or drugs omitted. The CP's responsibility is to identify any irregularities and report them to the facility. On 6/5/23 at 10:24 AM, the surveyor interviewed the CP via telephone, who stated that he was covering for the regular CP during April and May and was familiar with the reports. The CP stated that he had reviewed with the LNHA the charting omissions he had noticed. The CP also said that he emailed the CP reports to the facility, and it was the facility's responsibility to respond to the recommendations. The surveyor continued to meet with the LNHA to review the components of the Removal Plan (RP) necessary to remove the immediacy on 6/6/23 at 12:45 PM, 6/7/23 at 10:00 AM, and 12:40 PM when the RP was not provided. On 6/08/23 at 10:45 AM, the surveyors reviewed the RP sent by the facility, and after review, it was rejected based on insufficient evidence, which was needed to remove the immediacy. The surveyor discussed this with the LNHA. After the facility revised the RP, they were accepted. On 6/8/23 at 10:30 AM, the surveyor interviewed the Medical Director (MD), who stated that he was unaware of concerns about the quality issues of missing blood sugars and insulin coverage. MD added, If I had known that, I would have addressed that at our quality meetings. The MD stated that he had not gotten medication error reports from the facility. He also said he did not know why the facility did not notify him of the pharmacy consultant's recommendations. On 6/8/23 at 12:00 PM, DON stated that the pharmacy consultant's recommendations go to the LNHA, and then they are given to the DON, and sometimes there is a delay. DON did not indicate if she was aware of this recommendation made by the pharmacist. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview, and review of records. NJAC 8:39-27.1(a)

Refer to F756K, F689L, F835L and F836L Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents are free of significant medication errors regarding the documentation and administration of critical medications, including anticoagulants and insulin medications to prevent serious adverse outcomes for Resident #13, #19 and #20 who required blood sugar monitoring and were dependent on insulin, Resident #17, #25 and #230 who had physician orders for an anticoagulant to prevent blood clotting, and Resident #19 who had a physicians order for an oral hypoglycemic agent (medications to lower blood sugar). The facility failed to ensure that Resident #18 was given medication validated by the physician, and the pharmacy, reviewed for allergies, and entered into the Electronic Medication Administration Record (eMAR) to prevent serious adverse outcomes, including significant allergic reactions. The failure to monitor and document blood sugars and administer insulin and oral hypoglycemic agents when indicated per the physician's order is likely to result in hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), which requires immediate emergency intervention if symptomatic. The failure to administer and document an anticoagulant in accordance with a physician's order to prevent blood clots is likely to lead to a heart attack, pulmonary embolism (a blood clot that enters the lung), anoxic stroke (a blood clot that stops oxygen to the brain), or other blood clots throughout the body. Resident #25 received double dosing of an anticoagulant medication for five days, likely leading to increased bleeding, which would require immediate emergency intervention. The failure to give a medication validated by the physician, the pharmacy, reviewed for allergies, and entered into the eMAR is likely to lead to significant allergic reactions, which would require immediate emergency intervention. This resulted in an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 6/1/23, which began on 3/7/23 (the start date on which the Consultant Pharmacist (CP) alerted the facility of concerns on documentation of medications on the eMAR) and continued until 6/8/23 when the facility implemented their written removal plan. The facility's Licensed Nursing Home Administrator (LNHA) was notified of the IJ on 6/1/23 at 4:28 PM. An acceptable written Removal Plan (RP) was received on 6/8/23. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview, and review of records. This deficient practice was identified for 7 of 17 residents reviewed for medication management (Resident #13, #17, #18, #19, #20, #25, and #230). The evidence was as follows: 1. On 5/24/23 at 10:40 AM, the surveyor observed Resident #19 out of bed to the wheelchair in the dining area, eyes closed, unable to answer the surveyor's inquiry. According to the Admission Record (AR), Resident #19 was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease (a progressive mental deterioration), type 2 diabetes mellitus (elevated level of blood sugar), and hypertension (high blood pressure). The surveyor reviewed the Quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) dated 3/03/23. The included Brief Interview for Mental Status (BIMS) referenced a score of 0, which identified that the resident's cognition was a severe impairment. A review of the Pharmacy Therapeutic Suggestions Sheets (consult sheet) Final Report revealed under Subject: Therapeutic suggestions dated 04/04/23, The eGFR was found to be 40ml/min on 5/2022. With moderate renal impairment (eGFR = 30-45 mL/min), the recommended dose of Januvia is 50 mg. Currently on 100 mg Januvia and HbA1c = 5.8. Recommended dose decrease. Accepted: handwritten signature by the doctor on 4/26/23. Handwritten order: Reduce Januvia to 50 mg daily. A review of the Progress Notes dated 4/26/23 at 13:00 revealed under Note Text: Visited by Dr. Segaram (for routine). Rcvd. NO. Decrease med dose of Januvia 100 mg to Januvia 50 mg tab 1 tab PO q.d in AM. r/t eGFR & HbA1C results. NO noted and carried out. A review of the Order Summary Report (OSR) for April 2023 revealed on 4/26/23 an order for Januvia Oral Tablet 50 MG (Sitagliptin Phosphate) Give 1 tablet by mouth in the morning for DM II. A review of the Order Summary Report (OSR) for April 2023 revealed on 3/01/23 an order for Januvia Oral Tablet 100 MG (Sitagliptin Phosphate) Give 1 tablet by mouth in the morning for DM 2. A review of the April 2023 and May 2023 electronic Medication Administration Reports (eMARs) revealed that Januvia 50 mg and Januvia 100 mg are reflected as both ordered until 05/31/23. A review of the April 2023 eMAR order for Januvia 100 mg reflected the following signatures showing the administration of the medication on 4/26 and 4/27. The April 2023 eMAR also showed orders for Januvia 100 mg and Januvia 50 mg reflected the following signatures showing the administration of both medications on 4/28, 4/29, and 4/30/23. A review of the May 2023 eMAR orders for Januvia 100 mg and Januvia 50 mg reflected the following signatures showing administration of both of the medications on 5/1, 5/3, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10, 5/11, 5/13, 5/14, 5/16, 5/17, 5/18, 5/19, 5/25, 5/26, and 5/30/23. On 05/30/23 at 11:11 AM, the surveyor interviewed a Licensed Practical Nurse (LPN #1), who stated that she worked in the facility for two years. LPN # 1 said that when the medication changed, the person who did the changes would be the one to write the order, she added that she does not have the time to follow the doctor's order, and usually, the Director of Nursing (DON) or Assistant Director of Nursing (ADON) would be the one carrying out that recommendation from the doctor and whoever takes the order from the doctor should be the one to enter it in the electronic health record. LPN #1 added that she accidentally signed the Januvia 100 mg, but the order should be deleted. On 5/30/23 at 11:45 AM, the DON stated that she picked up the order based on the recommendation of the pharmacy and carried out that specific order but forgot to check them one by one. A review of the facility policy revised 2023 revealed under Policy: 3. The Charge Nurse/ADON will make sure: a. All of the recommendations are acted upon. A review of the OSR for Resident # 19 dated 4/23 revealed on 3/01/23 an order for Novolog injection solution 100 unit/ml (Insulin Aspart) Inject as per sliding scale: if 70-130 =0; 131-180 =2; 181-240 =4; 241-300 =6; 301-350 =8; 351-400 =10 If above 400, give 10 units, then call MD for order, subcutaneously before meals and at bedtime for DM2. A review of the March 2023 eMAR did not show documentation of the critical medication novolog insulin administration for 45 of 120 doses due. A review of April 2023 eMAR did not show documentation of the administration of the critical medication Novolog insulin for 31 of 120 doses due. A review of May 2023 eMAR did not show documentation of the administration of the critical medication Novolog insulin for 65 of 120 doses due. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 99, which required no Humalog insulin, to 231, requiring 4 units of Humalog to be administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 111, which required no Humalog insulin, to 276, requiring 6 units of Humalog to be administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 100, which required no Humalog insulin, to 192, requiring 4 units of Humalog to be administered. There was no documentation revealing a blood sugar taken on each of the omitted insulin doses or documentation of hospitalization , hypoglycemia, or hyperglycemia. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. On 6/1/23 at 11:00 AM, the surveyor asked LPN #1 regarding the missing signatures, and LPN #1 stated that she was signing the medication she had been giving but could not speak for other nurses if they were signing or not, and the nurse added that she does not have time to check those signatures. 19106 2. The surveyor observed Resident #25 on 5/24/23 at 10:54 AM, receiving personal care from the Certified Nursing Assistant (CNA). The surveyor again observed the resident on 5/26/23 at 11:45 AM, awake in bed watching television. The resident was alert and oriented and able to answer simple questions. A review of the hybrid medical record revealed the following: According to AR, Resident #25 was admitted to the facility with diagnoses that included but were not limited to chronic embolism and thrombosis of unspecified deep veins of the left lower extremity (also known as DVT). The resident was care planned (5/29/23) for using anticoagulant therapy related to DVT. Interventions included: Administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness q [every] shift. Monitor/document/report PRN [as needed] adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black, tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s [vital signs]. Review the medication list for adverse interactions. Avoid the use of aspirin or NSAIDS. A 4/27/23 at 21:58 physician's phone order for Eliquis, an anticoagulant to prevent blood clotting and used to treat DVT, was entered into the electronic record by the nurse. The physician's order was written as follows: Eliquis Oral Tablet 5 MG (Apixaban) Give 2 tablet by mouth two times a day for DVT prophylaxis until 05/04/2023 21:59 Give 2 tabs x 5 mg to equal 10 mg/dose. Give BID [twice a day] x 7 days then 5 mg BID x 3 months thereafter. AND Give 1 tablet by mouth two times a day for DVT prophylaxis x 3 months. A 4/27/23 at 22:23 electronic provider pharmacy order note was written as follows: This order is outside of the recommended dose or frequency. The daily dose of 6 tablets exceeds the usual dose of 1 to 2 tablets. The frequency of 4 times per day exceeds the usual frequency of 2 times a day. The single dose of 2 tablets exceeds the maximum single dose of 1 tablet. The usual daily dose is 1 to 2 tablets. A second provider pharmacy order note dated and timed the same as the previous pharmacy order note alerted the facility the 4/27/23 new Eliquis order created a drug-to-drug interaction with two (2) other medications (aspirin and dicyclomine) with the potential of increased risk of bleeding. There was no evidence that the order notes were addressed by nursing staff. The April 2023 eMAR revealed the following Eliquis administration: On 4/28, 4/29, and 4/30 at 0900, 5 mg. and 10 mg. doses were both administered. On 4/28, 4/29, and 4/30 at 2100, 5 mg. and 10 mg. doses were both administered. The May 2023 eMAR included the exact incorrect double twice daily dosing on 5/1/23 and 5/3/23. On 5/2/23 eMAR documentation indicated the incorrect 0900 doses were administered, and double dosing was administered for the 2100 time slot. On 5/4/23 eMAR documentation indicated no 0900 doses were given, and double dosing was administered for the 2100 time slot. There were no nursing progress notes between 4/27/23 through 5/2/23 addressing the Eliquis order or an assessment of the resident regarding increased bleeding. The physician documented in a 5/3/23 at 12:54 Physician Progress Note, . Patient is to continue Eliquis 5 mg two tabs by mouth two times a day for DVT prophylaxis. The 5/4/23 CP monthly report included the following statement: Please clarify the order for Eliquis: the loading doses and maintenance doses were both charted starting 4/28/23, i.e., Eliquis 5 mg 1 tablet two times daily for 3 months & Eliquis 5 mg 2 tablets two times a day for 7 days. Were 3 tablets given cumulatively? Please review. The undated Action Taken response by the facility was updated all medication orders & directions. On 5/31/23 at 11:26 AM, the surveyor interviewed LPN #1, who stated she remembered when the resident started on Eliquis but did not recall if the resident received incorrect dosing from 4/28/23 to 5/4/23. She said she couldn't remember that far back. On 5/31/23 at 12:57 PM, the surveyor interviewed the DON, who stated she was unaware of the Eliquis dosing errors. DON said she would initiate an investigation of the errors. On 6/1/23 at 11:34 AM, the DON stated she had not completed the investigation. DON said the physician had not been notified of the Eliquis errors. On 6/1/23 at 4:13 PM, the surveyor interviewed LNHA regarding the Eliquis administration errors between 4/28/23 and 5/4/23. The LNHA stated she was unaware of the errors and would immediately begin a medication error report. On 6/2/23 at 10:10 AM, the surveyor interviewed the CP supervisor, who stated medication errors were brought to the nurse's attention. It is up to the nurse to follow up and do an investigation. The CP supervisor further stated that the CP identified the Eliquis error after it had occurred. The CP informed the facility and would review it on the next visit, which did not yet happen. On 6/5/23 at 1:44 PM, the DON stated she did not have a completed investigation, and the physician had not been notified. On 6/7/23 at 2:16 PM, the surveyor interviewed the Medical Director (MD) on the phone. The MD was also the primary physician for Resident #25. He was the prescriber for the 4/27/23 Eliquis; however, he stated he was unaware of the Eliquis medication errors. On 6/8/23 at 12:55 PM, the surveyor interviewed the MD on the phone. He stated he had not received medication error reports or CP monthly reports. There was no documentation revealing any blood clotting concerns identified nor any documentation of hospitalization for this resident. The facility policy and procedure for Medication Administration/eMAR was provided to the surveyor by the DON on 5/26/23. The policy was reviewed and signed by the LNHA in 2023 (no month was noted). Procedure #1 included the following verbiage . no medication/s must be administered except those reviewed and confirmed with the physician, validated with the pharmacy, and entered into electronic eMAR. Procedure #2 noted, . check to make sure [medication] is the. right dose. Procedure #4 noted, Check the label of the medication against the order on the resident's eMAR, making sure that everything matches including the . dose. Procedure #5 noted, Double check the resident's other medication orders to make sure there are no contraindications between the medications. 34421 3. On 5/31/23 at 11:40 AM, the surveyor observed Resident #20 in the resident's room in a chair. The resident's eyes were closed. The surveyor attempted to interview the resident, but the resident was unable to answer the surveyor's inquiry. According to the AR, Resident #20 was admitted to the facility with diagnoses that included but were not limited to type 2 diabetes mellitus, atrial fibrillation (AFib) (an irregular, rapid heart rate that typically requires anticoagulants to prevent blood clotting), and psychotic disorder. The surveyor reviewed the Quarterly MDS, with an ARD dated 5/7/23. The included BIMS referenced a score of 0, which identified that the resident's cognition was a severe impairment. The resident was care planned (11/14/2020) for the diagnosis of diabetes mellitus. Interventions included: Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. The resident was care planned (5/29/2) for using anticoagulant therapy. Interventions included: Administer anticoagulant medications as ordered by a physician . Monitor for side effects and effectiveness Q (every) shift. Monitor/document/report PRN [as needed] adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black, tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s [vital signs]. A review of the OSR for May 2023 revealed the following POs for Humalog (fast-acting insulin) injection solution 100 unit/ml (Insulin Lispro) dated 3/1/23. The order specified to inject the insulin subcutaneously (under the skin) as per the sliding scale: if the fasting blood sugar is 0-150, administer 0 units of insulin; if the fasting blood sugar is 151-180, administer 2 units of insulin; if the fasting blood sugar is 181-240, administer 4 units of insulin; if the fasting blood sugar is 241-300, administer 6 units of insulin; if the fasting blood sugar is 301-350, administer 8 units of insulin; if the fasting blood sugar is 351-400, administer 10 units of insulin; An additional PO dated 3/1/23 administered Lantus (long-acting insulin) subcutaneous solution 100 unit/ml (Insulin Glargine). The order specified injecting 15 units subcutaneously at bedtime for type 2 diabetes. In addition, there was an order for Xarelto (an anticoagulant) dated 3/1/23. The order specified administering Xarelto 15 milligram tablet by mouth in the evening for AFib. A review of March 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 37 of 120 doses due, Lantus for 12 of 31 doses due, and Xarelto for 8 of 31 doses due. A review of April 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 25 of 120 doses due, Lantus for 5 of 30 doses due, and Xarelto for 4 of 30 doses due. A review of May 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 49 of 120 doses due, Lantus for 15 of 30 doses due, and Xarelto for 13 of 30 doses due. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 58, which required no Humalog insulin, to 389, requiring 10 units of Humalog to be administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 39, which required no Humalog insulin, to 400, requiring 10 units of Humalog to be administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 74, which required no Humalog insulin, to 368, requiring 10 units of Humalog to be administered. There was no documentation revealing a blood sugar taken on each of the omitted insulin doses or documentation of hospitalization , hypoglycemia, or hyperglycemia. There was no documented evidence that the resident had a hospitalization . A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. 4. On 6/1/23 at 10:45 AM, the surveyor observed Resident #230 in a chair in the resident's room. The surveyor attempted to interview the resident, but the resident was unable to answer. According to the AR, Resident #230 was admitted to the facility with diagnoses that included but were not limited to AFib and dementia. The resident was care planned (5/27/23) for using anticoagulant therapy related to DVT. Interventions included: Administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness q [every] shift. Monitor/document/report PRN [as needed] adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black, tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s [vital signs]. Review medication list for adverse interactions. Avoid use of aspirin or NSAIDS. A review of the OSR for May 2023 revealed the following POs for Eliquis (an anticoagulant) 2.5 mg given 2.5 mg by mouth two times a day for AFib with a start date of 5/13/23. A review of May 2023 eMAR did not show documentation of the administration of the critical medications of Eliquis for 13 of 36 doses due. There was no documented evidence of hospitalization . A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. 34033 5. On 6/7/23 at 11:23 AM, the surveyor observed Resident #13 in bed. The resident was unable to answer any questions. According to the AR, Resident #13 was admitted to the facility with diagnoses that included but were not limited to dementia, AFib, and Type 2 diabetes mellitus (DM2). A review of the resident's Significant Change MDS with an ARD of 2/24/23, reflected the resident had a BIMS score of 5 out of 15, indicating that the resident had a severely impaired cognition. A review of the resident's individualized interdisciplinary care plan (IDCP) reflected as a Focus area with a date initiated and revised of 4/1/22, The resident is on anticoagulant therapy related to (r/t) Atrial Fibrillation (AFib) with an intervention Administer anticoagulant medications as ordered by the physician. Monitor side effects and effectiveness every shift. There was an additional Focus area with a date initiated and revised 3/28/22, Resident #18 has Diabetes Mellitus with interventions Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. Fasting serum blood sugar as ordered by the doctor. Monitor/document the resident/family's ability to manage the treatment program, i.e., medications, dietary, glucose monitoring, exercise, and knowledge of complications. Monitor/document/report PRN any signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggered gait. A review of the May 2023 OSR revealed the following Physician's Orders (PO): - start date of 3/1/23 Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth two times a day for A Fib. - start date of 3/1/23 HumaLog injection solution (Insulin Lispro), 100 Unit/ML, inject as per sliding scale: if 0-150=0; 151-200=2; 201-250=3; 251-300=4; 301-350=5;351-400=6, if above 400, give 8 units then recheck after 1 hour, subcutaneously (SC) before meals and at bedtime for DM2. - start date of 3/1/23 Lantus Subcutaneous Solution 100 Units/ML (Insulin Glargine), inject 16 units SC at bedtime for DM2. A review of the March 2023 eMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 10 out of 62 omitted doses. - Humalog had a total of 44 out of 124 omitted doses. - Lantus had a total of 13 out of 31 omitted doses. A review of the April 2023 EMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 6 out of 60 omitted doses. - Humalog had a total of 27 out of 120 omitted doses. - Lantus had a total of 6 out of 30 omitted doses. A review of the May 2023 eMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 26 out of 62 omitted doses. - Humalog had a total of 65 out of 124 omitted doses. - Lantus had a total of 18 out of 31 omitted doses. There was no documentation of blood sugar on each of the omitted insulin doses or documentation of hospitalization , hypoglycemia, or hyperglycemia. There was no documentation revealing any blood clotting concerns identified nor any documentation of hospitalization for this resident. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 98, which required no Humalog insulin, to 299, requiring 4 units of Humalog that were administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 80, which required no Humalog insulin, to 324, requiring 5 units of Humalog that were administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 103, which required no Humalog insulin, to 314, requiring 5 units of Humalog that were administered. 6. On 6/7/23 at 11:39 AM, the surveyor observed Resident #17 in a wheelchair at the back of the dining/day room. The resident ended a phone call using the facility telephone. The resident stated that they had called their physician because they wanted to check on something. The resident also said that they received their medications because they see LPN#1 all the time and knew that they were supposed to take their antibiotic, Augmentin, with food. The resident was unable to speak to all medications that were administered or what times they were administered. The surveyor reviewed the electronic medical record for Resident #17. A review of the AR revealed that the resident had diagnoses which included but were not limited to dementia and AFib. A review of the resident's quarterly MDS with an ARD of 3/10/23, reflected the resident had a BIMS of 15 out of 15, indicating that the resident had intact cognition. A review of the resident's IDCP reflected as a Focus area with a date initiated and revised of 4/1/22, The resident is on anticoagulant therapy related to (r/t) Atrial Fibrillation (AFib) with an intervention Administer anticoagulant medications as ordered by the physician. Monitor side effects and effectiveness every shift. A review of the May 2023 OSR revealed a PO with a start date of 3/1/23 for Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth every 12 hours for AFib. -start date of 3/1/23 Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth two times a day for A Fib. A review of the March 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 17 out of 62 omitted doses. A review of the April 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 10 out of 60 omitted doses. A review of the May 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 29 out of 62 omitted doses. There was no documentation revealing any blood clotting concerns identified nor any documentation of hospitalization for this resident. A review of the Progress Notes revealed no follow-up with the physician regarding medication omissions in the eMARs. A review of the CP recommendations and monthly evaluations for March, April, and May 2023 revealed no specific CP recommendation addressing omissions from the resident's eMAR. 7. On 5/25/23 at 8:46 AM, during the morning medication pass, the surveyor observed LPN #1 preparing seven (7) medications according to the eMAR for Resident #18. At that time, LPN #1 stated that she was the nurse who worked on the 11 PM to 7 AM shift and knew that Resident #18 had been sent to the hospital and returned after midnight with a prescription from the hospital emergency room (ER) physician for Keflex (a cephalosporin antibiotic). LPN #1 added that she wanted to start the Keflex and administer the medication with the other morning medications. LPN #1 then called the Assistant Director of Nursing/Registered Nurse (ADON/RN), who brought over to LPN #1 to show the surveyor a prescription dated 5/24/23 from a hospital ER physician for Cephalexin (Keflex) 500 milligram (MG) capsule, take 1 capsule (500 MG total) by mouth 3 times a day for 5 days. The ADON/RN stated that she was working on faxing the prescription to the provider pharmacy and entering the PO in the electronic computer system. LPN #1 said she had Keflex in the facility backup box, which was kept in the medication cart. The surveyor observed LPN #1 remove two (2) of the 250 MG capsules of Keflex from the backup box and place them in the medication cup with the seven (7) other medications she had prepared for Resident #18. The surveyor had not observed a PO for Keflex in the eMAR that LPN #1 was documenting for Resident #18. On 5/25/23 at 9:01 AM, the surveyor observed LPN #1 preparing thickened water and said she would administer the eight (8) medications to Resident #18. At that time, the surveyor stopped LPN #1 from administering the (8) medications, which included the Keflex capsules. The surveyor asked LPN #1 to review the eMAR for Resident #18. LPN #1 stated that the Keflex PO was not entered electronically and was not on the eMAR. The surveyor then asked LPN #1 to review Resident #18's eMAR profile, particularly the allergy indicated on the eMAR. LPN #1 checked the resident's profile and stated that the resident was allergic to Penicillin (PCN) (an antibiotic with a cross-sensitivity to Keflex). LPN #1 also stated that she could not administer the Keflex and would have to call the primary physician. The surveyor observed LPN #1 remove the two (2) 250 MG Keflex capsules from the medication cup. LPN #1 could not speak to what allergic reaction occurred if the resident received PCN or had received a cephalosporin medication in the past without a reaction. LPN #1 could also not speak to whether the primary physician had approved the PO for Keflex to be administered with a PCN allergy. On 5/25/23 at 9:09 AM, the surveyor interviewed LPN #1 in the presence of the DON and ADON/RN, who stated that she had assumed the emergency room physician had reviewed the allergies. The DON said that LPN #1 should not have assumed. The DON added that the ADON/RN called the primary physician for the resident, and they were waiting to verify whether the Keflex could be administered. At that time, LPN #1 stated that her usual procedure was to call the physician, review any medication orders from the hospital, and review the allergies with the physician. However, this was a different situation. On 5/25/23 at 9:20 AM, the surveyor inte[TRUNCATED]